Essential or secondary anal pruritus

Specialty: Gastrointestinal.

• Perianal pruritus
• chronic anal itching
• anal irritation

Why it occurs

• Persistent perianal moisture due to poor hygiene or excessive/aggressive hygiene with scented soaps and wet wipes
• Local benign colorectal pathology (prolapsed hemorrhoids, anal fissure, fistulas or rectocele that allow the leakage of mucus or microsphincters)
• Parasitic infections (enterobiasis due to Enterobius vermicularis, common in children but also in cohabiting adults), fungal (Candida albicans due to chronic use of topical corticosteroids or diabetes) or bacterial (beta-hemolytic streptococcus)
• Local inflammatory dermatoses (inverted psoriasis, lichen sclerosus, contact dermatitis allergic to dyes or fragrances in toilet paper)
• Diet rich in food irritants that reduce fecal pH (coffee, citrus fruits, chocolate, beer, tomatoes, spicy foods).

Initial workup

Detailed dermatological and proctological examination of the perianal region under good lighting, including digital rectal examination and anoscopy (ruling out fissures, fistulas, hemorrhoids or neoplasms of the anal canal) | Patch or tape test (Graham Test) on three consecutive mornings before grooming to look for Enterobius vermicularis eggs | Bacteriological and mycological culture of perianal smear in cases of moist erythema or suspected candidiasis | Perianal skin biopsy with punch in case of suspicion of intraepithelial neoplasia or dermatosis refractory to standard medical treatment.

Standard management

• Low potency topical corticosteroids — 1% hydrocortisone ointment applied in a thin layer twice a day for a maximum of 7-10 days to break the itching-scratching cycle, avoiding prolonged use due to the risk of perianal skin atrophy and fungal superinfection
• Local antifungals or antibacterials according to suspected etiology — clotrimazole or miconazole 2% cream if candidiasis is confirmed; 2% mupirocin if bacterial superinfection from scratching is suspected
• Anthelmintic treatment in case of pinworms — mebendazole 100 mg orally in a single dose, mandatory repeating after two weeks for the entire cohabiting family nucleus
• Protective barrier creams with zinc oxide or water-based paste (applied after each bowel movement to protect the skin from contact with the acidity of feces and humidity).