What can I do about rectal itching?

Management of Rectal Itching

Start with a 2-week course of 1% hydrocortisone ointment applied to the perianal area 3-4 times daily, combined with strict perianal hygiene measures and barrier emollients, as this provides the most effective evidence-based treatment for primary pruritus ani. 1, 2

Initial Assessment and Diagnosis

Before treating, you must distinguish between primary (idiopathic) pruritus ani and secondary causes:

• Examine for visible skin lesions, hemorrhoids, fissures, or signs of infection (fungal, bacterial, pinworms, sexually transmitted infections including condyloma) 3, 4
• Screen for systemic causes if symptoms are severe or refractory: consider diabetes, liver disease, lymphoma, or other malignancies 3, 5
• Review medications that may cause pruritus, particularly opioids and chloroquine 5, 6
• Assess for fecal soiling or incontinence as these are common primary triggers 3, 7

First-Line Treatment Algorithm

Step 1: Hygiene and Barrier Protection (All Patients)

• Clean the perianal area with mild soap and warm water after bowel movements, pat dry gently rather than rubbing 2, 4
• Apply barrier emollients to protect skin from moisture and irritants 4, 7
• Eliminate potential dietary irritants: coffee, tea, cola, chocolate, citrus fruits, tomatoes, spicy foods, and beer 7
• Avoid scratching and use cotton underwear to reduce irritation 7

Step 2: Topical Corticosteroid Therapy

Apply 1% hydrocortisone ointment to the affected perianal area 3-4 times daily for 2 weeks. This achieves a 68% reduction in itch severity and 81% improvement in skin appearance. 1, 2

• Do not use for more than 2-4 weeks continuously to avoid skin atrophy 2
• Avoid in children under 2 years without physician supervision 2
• This is FDA-approved specifically for external anal itching 2

Second-Line Options for Refractory Cases

If symptoms persist after 2-4 weeks of hydrocortisone:

• Topical capsaicin cream can be effective for chronic refractory pruritus ani 4
• Tacrolimus ointment is an alternative for cases not responding to corticosteroids 4
• Consider topical doxepin (limited to 8 days, maximum 10% body surface area, 12g daily maximum) 6, 8

When to Suspect and Treat Secondary Causes

Infectious Causes

• If perianal abscess is suspected (swelling, tenderness, cellulitis): requires incision and drainage, with antibiotics only if systemic signs present 6
• If sexually transmitted proctitis is suspected (in sexually active patients, especially men who have sex with men): test for gonorrhea, chlamydia, herpes, and syphilis 6
• If pediculosis pubis (pubic lice) is identified: treat with permethrin 1% cream rinse or pyrethrins with piperonyl butoxide, applied for 10 minutes then washed off 6

Systemic Causes

If generalized pruritus is present beyond the perianal area:

• Obtain liver function tests, renal function, complete blood count, and thyroid function 5
• For hepatic pruritus: rifampicin is first-line, cholestyramine second-line 5
• For uremic pruritus: optimize dialysis and consider phototherapy 5

Critical Pitfalls to Avoid

• Do not use crotamiton cream or calamine lotion - these are ineffective for pruritus ani 6
• Avoid long-term sedating antihistamines (hydroxyzine, diphenhydramine) except in palliative settings, as they may increase dementia risk 5, 8
• Do not apply topical treatments to eyes if treating nearby areas 6
• Recognize that most antihistamines are ineffective for non-histamine-mediated pruritus ani, though non-sedating options like fexofenadine 180mg may be tried if other measures fail 8, 9

Referral Indications

Refer to colorectal surgery if:

• Symptoms persist despite 4-6 weeks of appropriate treatment 4
• Underlying anorectal pathology is identified (hemorrhoids, fissures, fistulas) 4
• Malignancy cannot be excluded 3, 4
• Recurrent perianal abscesses suggest fistula formation 6