Background: Idiopathic perianal pruritus is a poorly managed condition. Topical corticosteroids are effective in idiopathic perianal pruritus, but they may cause some side effects. In this study, the effectiveness of topical steroids were compared with perianal cleansers in the treatment of idiopathic perianal pruritus.
Patients and methods: Seventy two patients with the complaint of perianal pruritus were evaluated; 60 of the 72 patients were found to be idiopathic. Twenty eight patients were treated with topical steroids and 32 patients were treated only with a liquid cleanser.
Results: At the end of this two week period, cleansers were found to be as effective as topical corticosteroids.
Conclusion: This study shows that perianal cleansers can be used as a safe first step treatment in idiopathic perianal pruritus.
- idiopathic perianal pruritus
- topical corticosteroid
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Perianal pruritus is a common symptom, defined as an unpleasant cutaneous sensation that induces scratching of the skin around the anal orifice.1 Itchiness of the perianal skin can be a dermatological, proctological, or psychological disorder.2 Persistent perianal pruritus is a generally poorly managed, common, and socially embarrassing condition.3 There are many different causes of perianal pruritus such as haemorrhoids, anal fistula and fissures, inflammatory bowel disease, dermatoses (atopic dermatitis, psoriasis, lichen planus, Bowen’s disease, extramammary Paget’s disease, allergic contact dermatitis), local infections (candidiasis, dermatophyte infections, parasites, condyloma lata), benign and malignant anal tumours, generalised pruritus, foods (spices, citrus fruits, coffee, tea, chocolate, tomatoes), and psychogenic causes (table 1). The most difficult patients are the ones with extensive pruritus without physical signs.3–5 When no demonstrable cause is found, it is often described as idiopathic perianal pruritus.3 There are many treatment modalities for idiopathic perianal pruritus, including topical corticosteroids, topical non-steroid anaesthetics, and systemic antihistamines.6,7 Topical corticosteroids are known to be effective for non-fungal types of perianal pruritus.6 In this study, we tried to compare the effectiveness of topical steroids and perianal cleansing in the treatment of idiopathic perianal pruritus.
PATIENTS AND METHODS
Seventy two patients who presented to Gazi University Hospital Department of Dermatology with the complaint of perianal pruritus over a 24 month period were evaluated. All of the patients were first examined dermatologically. From perianal scrapings, native preparations were performed for fungal investigation. Perianal swabs for bacterial cultures were also performed. Complete blood counts, fasting glucose levels, liver and kidney function (alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, lactate dehydrogenase, blood urea nitrogen, creatinine), and total cholesterol and triglyceride levels were recorded. Investigation of faeces for parasites was also performed. In 11 patients, allergic contact dermatitis was suspected clinically and patch tests with both European Standard Series and personal items were performed. In 12 patients the causes of perianal pruritus were detected, and these patients with a defined cause were not included in our study. Sixty patients were classified as having “idiopathic perianal pruritus patients”. Twenty eight patients (group I) were treated with topical steroids (Advantan cream) twice daily for two weeks, and 32 patients (group II) were treated only with a liquid cleanser (Protex liquid cleanser) twice daily for two weeks. At the end of the two week period, the patients were re-examined. In both examinations (before and after treatment), patients were requested to score their pruritus in the range of 0–10 (0: no pruritus, 10: the most severe pruritus).
The χ2 test was used for statistical significance. Statistical analysis was performed using software SPSS 11.0 (Statistical Package for Social Science 11.0); a p value less than 0.05 was considered significant.
In 12 patients, the cause of perianal pruritus was detected (haemorrhoids, n = 4; anal fissure, n = 1; Enterobius vermicularis infestation, n = 1; dermatophyte infection, n = 1; condyloma accuminata, n = 1; perianal molluscum contagiosum, n = 1; diabetes mellitus, n = 1; and psychogenic factors, n = 2) and these patients were excluded from the study (table 2). In 11 patients, allergic contact dermatitis was suspected clinically and patch tests with both European Standard Series and personal items were performed. No allergic or irritant reaction was seen in these patients.
The mean (SD) age of the idiopathic perianal pruritus patients was 34.78 (16.68); 35 patients were male (58.3%) and 25 were female (41.7%). Twenty eight patients (mean (SD) age 35.43 (16.32), 16 male, 12 female) were treated with topical steroid (Advantan cream; Schering) twice daily and treatment was effective in 26 (92.3%). Thirty two patients (mean (SD) age 34.20 (15.35), 19 male, 13 female) were treated with a liquid cleanser (Protex liquid cleanse; Colgate-Palmolive) and treatment was effective in 29 (90.6%). The difference between the effectiveness of these two treatment modalities was not statistically significant (χ2 p>0.05).
Perianal pruritus is an extremely common symptom and is associated with a wide range of mechanical, dermatological, infectious, systemic, and other conditions.8
Inspection, palpation, and anoscopic examination should be performed to find out the aetiology. In this study, a total of 72 patients suffering from perianal pruritus were examined. The aetiology of perianal pruritus was found in only 12 (20%) of our patients.
Haemorrhoids and anal fissures are important causes of perianal pruritus. Daniel et al diagnosed haemorrhoids in 20% and anal fissures in 12% of patients with perianal pruritus.8,9 During our study, we diagnosed haemorrhoids in four patients and anal fissure in one patient, which were excluded from statistically analysed “idiopathic perianal pruritus” group.
There are many other organic and metabolic factors of perianal pruritus such as intestinal parasites, perianal fungal, bacterial and viral infections, and diabetes mellitus. It is important to treat the underlying aetiological factors, if detected In our study, “Enterobius, vermicularis infestation” was detected in a 5.5 year old girl. In one patient, perianal molluscum contagiosum was present. Perianal condyloma accuminata was diagnosed in another patient. Diabetes mellitus was diagnosed in one patient and in another dermatophyte infection was found with direct microscopic investigation.
Psychological problems are well known causes of perianal pruritus. Laurent et al showed that the mean hypomania and depression scale scores were greater and smaller respectively in the idiopathic perianal pruritus patients.10 In two of our patients, depression was diagnosed after psychiatric consultation.
There are many other factors known to initiate or aggravate perianal pruritus. It is very important to remember that some foods, such as spices, citrus fruits, coffee, tea, chocolate, and tomatoes can cause perianal pruritus.4,5 Such foods should be eliminated from the diets of patients as part of the treatment.5,11,12
Faecal contamination is also very important in perianal pruritus.13,14 Faeces contain endopeptidases of bacterial origin, in addition to potential allergens and bacteria. Although Silverman et al could not show a microbiological basis for perianal pruritus,15 these enzymes are capable of both itching and inflammation.13 At that point, we decided to investigate the role of decreasing faecal contaminants with cleansers and find out the effectiveness of washing in the treatment of perianal pruritus.
If a specific cause of perianal pruritus is identified, appropriate therapy such as antifungals, antibiotics, and antihelmintics should be given.6 There are many treatment modalities for idiopathic perianal pruritus, including topical corticosteroids, topical non-steroid anesthetics, and systemic antihistamines.6,7 Topical corticosteroids are widely used and they are one of the most effective treatment regimens for perianal idiopathic pruritus.6
In this study, we tried to compare the effectiveness of perianal cleansing and topical corticosteroids in the treatment of idiopathic perianal pruritus. Symptoms of 26 (92.9%) patients in group I, and 29 (90.6%) patients in group II improved. No side effects in either group were detected at the end of the treatment period. Although topical corticosteroids are one of the most effective treatment regimens for perianal idiopathic pruritus, the skin of anogenital area is particularly vulnerable to atrophy after the use of such medications.6,16 Although we did not detect such complications, topical corticosteroids, especially if used for a long period, can cause atrophy, bacterial and fungal infections, allergic contact dermatitis, telengectasia, purpura, and/or scar formation.17
In conclusion, this study shows that perianal cleansing is as effective as topical corticosteroids in the treatment of idiopathic perianal pruritus, and mild cleansers can be used as a safe first step treatment for controlling perianal itching.
Components of topical steroid and liquid cleanser
Advantan cream: methylprednisolone aceponate 0.1%.
Protex liquid cleanser: sodium lauryl ether sulphate; DMDM hidantoine; glycerin; cocodiethanolamide; triclosan; aloe vera extract; cocoamidoprpyl betaine; citric acid; EDTA; NaCl.