What ointment is recommended for treating perianal itching (pruritus ani)?

Treatment of Perianal Itching (Pruritus Ani)

For perianal itching, apply topical hydrocortisone cream (1-2.5%) to the affected area 3-4 times daily for up to 7 days maximum, combined with perianal hygiene measures and elimination of irritants. 1

First-Line Topical Corticosteroid Therapy

• Hydrocortisone 1-2.5% cream or ointment is the primary treatment, applied to the perianal area 3-4 times daily after gently cleaning with mild soap and warm water, then patting dry 1, 2
• Ointment formulations are preferred over creams as they provide better barrier protection and less irritation 3
• Treatment duration must not exceed 7 days to prevent cutaneous atrophy, skin thinning, and increased trauma risk 4, 5
• For children under 12 years, consult a physician before use 1

Essential Perianal Hygiene Measures

• Clean the perianal area with mild soap and warm water after bowel movements, then gently pat dry with soft toilet tissue or cloth 1, 2
• Avoid excessive cleaning, vigorous rubbing, or use of harsh soaps, as these worsen inflammation and perpetuate the itch-scratch cycle 3, 2
• Discontinue all other topical agents, wipes, or over-the-counter preparations that may contain irritants 2
• Keep the area dry throughout the day; moisture from incomplete drying or sweating exacerbates symptoms 2

Dietary Modifications

• Eliminate common dietary irritants including coffee, tea, cola, chocolate, tomatoes, citrus fruits, and spicy foods for 2 weeks to assess response 2
• Address bowel irregularity with fiber supplementation if stools are poorly formed or evacuation is incomplete, as fecal soiling is a primary cause in 48-50% of cases 2

Adjunctive Topical Treatments

• Emollients such as sorbolene should be applied regularly to maintain skin barrier function and prevent xerosis 3
• Topical lidocaine-based composite ointments (over-the-counter preparations with barrier and antimicrobial properties) demonstrated 90% symptom resolution within 2 weeks in recent studies, with most patients improving within 72 hours 6
• Capsaicin cream may be considered for refractory cases, though it requires patient tolerance of initial burning sensation 3

Systemic Treatment for Refractory Cases

• If topical therapy fails after 2 weeks, add non-sedating antihistamines: loratadine 10 mg daily or fexofenadine 180 mg daily 5
• For nocturnal itching disrupting sleep, use sedating antihistamines at bedtime: diphenhydramine 25-50 mg or hydroxyzine 25-50 mg 5

Critical Pitfalls to Avoid

• Never use high-potency corticosteroids (betamethasone, clobetasol) in the perianal area, as the thin, occluded skin dramatically increases systemic absorption and atrophy risk 4, 5
• Do not continue topical corticosteroids beyond 7 days even if symptoms persist; reassess for secondary causes instead 4, 5, 1
• Avoid applying multiple over-the-counter preparations simultaneously, as patients often worsen their condition through polypharmacy 2

Mandatory Reassessment Algorithm

• Reassess after 2 weeks if no improvement occurs to evaluate for secondary causes including pinworm infection (especially in children), fungal infections, psoriasis, erythrasma, or underlying anorectal disease 7, 2
• Perform stool examination for ova and parasites, skin scrapings for fungi, and anoscopy to identify hemorrhoids, fissures, or other structural problems 2
• Consider referral to colorectal surgery if benign anorectal disease (hemorrhoids, fissures, fistulas) is identified, as correction of these problems should precede other management 2
• Rule out rare but serious causes including anal intraepithelial neoplasia or squamous cell carcinoma if symptoms are unilateral, indurated, or non-responsive to standard therapy 7