What is the treatment for pruritis ani?

Treatment of Pruritus Ani

Start with perianal hygiene optimization and topical hydrocortisone cream, as idiopathic pruritus ani responds best to anal cleanliness, dietary modification, bowel habit regulation, and mild topical corticosteroids. 1

Initial Management Approach

First-Line Conservative Measures

• Perianal hygiene: Keep the area scrupulously clean and dry—fecal residue and moisture are the most damaging factors 2

  • Clean gently with mild soap and warm water after bowel movements, rinse thoroughly, and pat dry 3
  • Avoid overzealous cleaning, which paradoxically worsens the condition 1

• Topical hydrocortisone: Apply 1% hydrocortisone cream to affected area 3-4 times daily 3, 1

  • This is effective for idiopathic pruritus ani and provides relief for inflammation and itching 1
  • Avoid long-term potent steroids, as they can damage perianal skin 2

• Dietary modification: Eliminate potential food irritants 1, 4

  • Common culprits include coffee, tea, cola, chocolate, citrus fruits, tomatoes, and spicy foods 4
  • Trial elimination of specific items identified by patient history 1

• Bowel habit regulation: Address poorly formed stools or incomplete evacuation, as 48-50% of patients have soiling issues 1

  • Optimize stool consistency to prevent fecal soiling 4

Critical Pitfalls to Avoid

• Stop all topical anesthetics and multiple medications: Patients often worsen the problem by applying numerous over-the-counter preparations 1, 2
• Avoid scratching: This perpetuates the itch-scratch cycle 2
• Do not use crotamiton cream or topical capsaicin: These are ineffective for pruritus of unknown origin 5

When Conservative Measures Fail

Investigate Secondary Causes

If symptoms persist after 2-4 weeks of conservative management, consider:

• Dermatological evaluation: 34 of 40 patients (85%) in one study had an underlying dermatosis as the cause 6

  • Common findings include psoriasis, eczema, contact dermatitis, or erythrasma 1, 6
  • Patch testing may reveal contact sensitivities to topical medications (18 of 40 patients had positive reactions) 6

• Anorectal pathology: Correct minor surgical problems (hemorrhoids, fissures, fistulas) before other treatments 1

  • Perform digital rectal exam, proctoscopy, and sigmoidoscopy 6

• Infectious causes: Rule out fungal infections (skin scrapings), pinworms (stool for ova and parasites), or sexually transmitted diseases 1, 4, 5

  • For pinworm (Enterobius vermicularis): Most common symptom is pruritus ani; treat with albendazole 400 mg PO as single dose 5

• Systemic diseases: Consider diabetes, liver disease, renal disease, lymphoma, or other malignancies if clinically indicated 4

Escalation for Refractory Cases

For persistent idiopathic pruritus ani despite conservative measures:

• Topical menthol or pramoxine: Consider refrigerated preparations for symptomatic relief 5
• Oral antihistamines: Non-sedating agents (loratadine 10 mg daily, cetirizine 10 mg daily) for daytime; sedating agents (hydroxyzine 25-50 mg) for nighttime pruritus 5
• Gabapentin or pregabalin: Second-line for neuropathic component (gabapentin 900-3600 mg daily; pregabalin 25-150 mg daily) 5

Reassurance and Psychological Factors

• Address cancer concerns: Many patients worry that cancer causes their symptoms; reassurance alone helps some patients tolerate the condition 1
• Referral to dermatology: This may be more appropriate than colorectal surgery as first-line specialist referral, given the high prevalence of dermatological causes 6