What is the best treatment for anal itching (pruritus ani)?

Treatment for Anal Itching (Pruritus Ani)

For anal itching (pruritus ani), topical moderate-potency corticosteroids such as 1% hydrocortisone ointment are the most effective first-line treatment, providing significant symptom relief while addressing underlying inflammation. 1

Stepwise Treatment Approach

First-Line Treatment

• Topical corticosteroids:
  • 1% hydrocortisone ointment applied to affected area 2-4 times daily 2, 1
  • Clinical evidence shows 68% reduction in itching symptoms and 81% improvement in skin appearance 1
  • Apply for 1-2 weeks; do not exceed recommended dosage 2
  • For external use only; avoid contact with eyes 2

Second-Line Options (if first-line fails after 2 weeks)

• Oral antihistamines:

  • Non-sedating antihistamines (daytime): loratadine 10mg daily 3
  • Sedating antihistamines (nighttime): diphenhydramine 25-50mg or hydroxyzine 25-50mg 3
  • Consider combination of H1 and H2 antagonists in resistant cases 3

• Topical alternatives:

  • Menthol 0.5% preparations for cooling relief 3
  • Lotions containing urea or polidocanol 3

For Severe or Refractory Cases

• GABA agonists: pregabalin (25-150mg daily) or gabapentin (900-3600mg daily) 3
• Other medications to consider:
  • Doxepin (topical or oral) 3
  • Capsaicin (topical) 4
  • Tacrolimus (topical) 4

Essential Supportive Measures

Hygiene and Lifestyle Modifications

1. Proper cleansing:

   • Clean perianal area with mild soap and warm water 2
   • Pat dry thoroughly (avoid rubbing) 4
   • Consider using soft, unscented toilet paper or moist wipes without alcohol

2. Eliminate irritants:

   • Avoid scented soaps, wipes, or toilet paper
   • Wear loose cotton underwear
   • Avoid scratching (which perpetuates the itch-scratch cycle)

3. Skin protection:

   • Keep area dry and clean
   • Consider zinc oxide barrier creams between treatment applications

Common Pitfalls and Caveats

• Failure to identify underlying causes: 25-75% of pruritus ani cases have co-existing pathology 5
• Overuse of topical steroids: Limit use to 2-3 weeks to prevent skin atrophy
• Inadequate follow-up: Reassess after 2 weeks; if symptoms persist or worsen, investigate for secondary causes 3
• Missing serious conditions: Rule out malignancy, infections, and inflammatory conditions if symptoms persist 4, 6
• Patient embarrassment: Patients often delay seeking treatment due to embarrassment 4

Special Considerations

• For elderly patients: Use moisturizers with high lipid content before considering medications 3
• For pregnant women: Avoid certain medications; consult specialist if symptoms persist
• For children under 2 years: Do not use hydrocortisone without physician supervision 2

The evidence strongly supports that topical corticosteroids, particularly 1% hydrocortisone ointment, provide the most effective relief for anal itching while addressing the underlying inflammatory component that perpetuates symptoms 1. Combined with proper hygiene measures and elimination of irritants, this approach resolves symptoms in the majority of patients.