Management of Pruritus Ani
The most effective first-line treatment for pruritus ani is maintaining proper perianal hygiene combined with the application of 1% hydrocortisone ointment, which can reduce itching by up to 68% compared to placebo. 1
Initial Assessment and Diagnosis
Pruritus ani can be classified as:
- Primary/Idiopathic: No identifiable cause (often related to fecal soiling or dietary factors)
- Secondary: Due to underlying conditions
Key diagnostic considerations:
- Evaluate for fecal soiling or incomplete evacuation (present in 48-50% of cases) 2
- Check for underlying skin conditions (psoriasis, eczema) 3
- Assess for anorectal diseases (hemorrhoids, fissures)
- Consider infectious causes (fungal, bacterial, parasitic)
- Rule out systemic diseases (diabetes, liver disease)
Treatment Algorithm
Step 1: Perianal Hygiene and Lifestyle Modifications
- Gentle cleansing after bowel movements with plain water or mild soap
- Pat dry rather than rubbing
- Avoid harsh soaps, scented toilet paper, and excessive cleaning 4
- Dietary modifications: Eliminate potential trigger foods (coffee, chocolate, citrus, tomatoes, spicy foods)
- Bowel habit regulation: Address constipation or diarrhea
Step 2: Topical Treatments
- 1% Hydrocortisone ointment: Apply to affected area 3-4 times daily for up to 2 weeks 5, 1
- Reduces itching by 68% compared to placebo
- Improves skin appearance by 81%
- Improves quality of life by 75%
- Avoid prolonged use of potent steroids to prevent skin atrophy
Step 3: For Persistent Symptoms
- Patch testing to identify contact sensitivities (18/40 patients in one study had positive patch tests) 3
- Treat underlying conditions:
- Antifungals for fungal infections
- Antibiotics for bacterial infections
- Antiparasitics for parasitic infections
Step 4: Refractory Cases
- Referral to combined colorectal and dermatological clinic for specialized management 3
- Consider capsaicin cream for adults (apply thin film 3-4 times daily) 6
- For hepatic pruritus, consider rifampicin as first-line treatment 7
Special Considerations
For Pruritus Related to Systemic Diseases
- Hepatic pruritus: Consider rifampicin as first-line, cholestyramine as second-line, sertraline as third-line 7
- Uraemic pruritus: Consider capsaicin cream, topical calcipotriol, or oral gabapentin 7
- Iron deficiency: Iron replacement therapy 7
Common Pitfalls to Avoid
- Overtreatment: Excessive cleaning and multiple medications often worsen symptoms 2
- Overlooking contact dermatitis: Many patients develop sensitivity to topical medications 3
- Missing underlying causes: 34/40 patients in one study had recognizable dermatosis 3
- Long-term use of sedative antihistamines: May predispose to dementia except in palliative care 7
Follow-up
- Reassess after 2 weeks of treatment
- If symptoms persist, reconsider diagnosis and evaluate for secondary causes
- For patients with recurrent symptoms, consider maintenance therapy with gentle cleansing and intermittent low-potency steroid use
Most patients with pruritus ani can achieve significant symptom improvement with proper perianal hygiene and appropriate use of topical treatments, particularly 1% hydrocortisone ointment.