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

Treatment of Anal Itching (Pruritus Ani)

Start with 1% hydrocortisone ointment applied 3-4 times daily for up to 7 days maximum, combined with strict perianal hygiene measures—this approach resolves symptoms in approximately 68% of cases and is supported by both FDA approval and randomized controlled trial evidence. 1, 2

Immediate First-Line Management

Topical Corticosteroids (Primary Treatment)

• Apply hydrocortisone 1-2.5% ointment to the perianal area 3-4 times daily for maximum 7 days 1, 2
• Before application, clean the affected area with mild soap and warm water, rinse thoroughly, and gently dry by patting with toilet tissue or soft cloth 1
• This produces a 68% reduction in itch severity and 81% improvement in clinical appearance 2
• Critical warning: Do not exceed 7 days of continuous use to prevent cutaneous atrophy and skin fragility 3, 4

Essential Concurrent Hygiene Measures (Mandatory for All Patients)

• Apply emollients at least once daily to prevent xerosis, which commonly triggers pruritus 4
• Avoid moisture accumulation in the perianal region—keep area dry after bathing using clean, separate towels 4
• Eliminate soaps, harsh detergents, and wool clothing from contact with the area 4
• Increase dietary fiber intake to prevent fecal soiling 5, 6, 7
• Avoid potential food irritants 5, 6

When Initial Treatment Fails After 2 Weeks

Second-Line Topical Options

• Topical menthol 0.5% can be added for symptomatic relief through counter-irritant effect 3
• Consider topical doxepin (limit to 8 days maximum, 10% body surface area, 12 grams daily due to contact dermatitis risk) 4
• Do NOT use capsaicin cream—there is no evidence of efficacy for anal pruritus 3, 6

Systemic Antihistamines (If Topical Treatment Inadequate)

• For daytime pruritus: loratadine 10 mg daily or fexofenadine 180 mg daily 3, 4
• For nocturnal pruritus: diphenhydramine 25-50 mg or hydroxyzine 25-50 mg at bedtime 3

Third-Line Neuropathic Agents (Refractory Cases)

• Gabapentin 900-3600 mg per day or pregabalin 25-150 mg per day if antihistamines fail 3

Identify and Treat Secondary Causes

Most Common Treatable Causes

• Candidiasis (most frequent cause): 7 days of topical azole treatment achieves 80-90% cure rate 3
• Perianal/perirectal abscess: requires prompt surgical drainage plus antibiotics if systemic signs present, immunocompromised, or significant cellulitis 8
• Sexually transmitted infections: evaluate for HSV, gonorrhea, chlamydia, syphilis if recent receptive anal intercourse 8
• Pinworms, scabies, or pediculosis: treat with appropriate antiparasitic agents 8

When to Suspect Serious Pathology

• Off-midline fissures mandate evaluation for Crohn's disease, HIV/AIDS, tuberculosis, syphilis, leukemia, or cancer 8
• Persistent symptoms despite appropriate treatment require anoscopy and digital rectal examination 8, 6, 7

Advanced Treatment for Intractable Cases

Novel Topical Composite Agents

• Composite lidocaine ointments with epidermal barrier and antimicrobial effects achieve 90% symptom resolution within 2 weeks, with most patients improved within 72 hours 9
• Apply twice daily 9

Invasive Options (Last Resort)

• Intradermal methylene blue injection may provide long-lasting relief for truly refractory cases 6
• Tacrolimus 0.1% ointment can be considered 6

Critical Clinical Pitfalls to Avoid

• Never continue topical corticosteroids beyond 7 days—this causes irreversible skin atrophy and increased trauma risk 3, 4
• Never perform instrumentation (anoscopy) during acute severe pain—this is traumatic and rarely diagnostic; consider examination under anesthesia instead 8
• Never assume idiopathic pruritus ani without excluding secondary causes—25-75% have identifiable pathology 7
• Do not use crotamiton cream—it has no antipruritic effect versus placebo 4

Mandatory Reassessment Protocol

• Reevaluate after 2 weeks if no improvement or worsening occurs 3, 4
• If symptoms persist beyond initial treatment, systematically advance through treatment tiers rather than continuing ineffective therapy 3, 4
• Consider referral to colorectal surgery for examination under anesthesia if diagnosis remains unclear or symptoms are intractable 8, 7