Itchy Butt and the Burn

1. 2/2/11 Itchy Butt and the Burn

2. Perianal skin • Subject to virtually all the diseases that affect the rest of the skin • Requires accurate diagnosis to eliminate diseases with specific cause and treatment • Organized approach to diagnosis • Frequent biopsy • Must properly examine the anus with appropriate instruments and bright light

3. PruritusAni • Of Latin derivation meaning itchy anus • Primary • Classic syndrome of idiopathic pruritusani • Secondary • Identifiable cause or specific diagnosis • Macules • Flat spots • Papules • Elevated, circumscribed solid lesions, raised spots • Bulla • Larger vesicles or blisters

4. PruritusAni • Pustules • Contain pus • Ulcers • Surface lesions with loss of continuity of the skin and result from rupture of vesicular lesions, infection, or trauma • Intertrigo • Inflammation seen between two opposing skin surfaces (mixed infxn assoc with moisture, obesity, and poor hygiene)

5. Physiologic Considerations • Surface phenomenon mediated by pain fibers • In the epidermis • May have lower threshold for stimulation than pain • Innocuous, nondamaging stimuli may induce itching • Histamine, kallikrein, bradykinin, papin, and trypsin produce itching that don’t respond to histamine antagonists

6. Scratching • Scratching with subsequent injury may produce an enlarged patch of itchy skin • Produces inadequate feedback to inhibit itching • More scratching occurs with cutaneous injury • Provides more stimulus to scratch • Self-defeating loop • Substituting heat, cold, pain or stinging may provide an inhibitory feedback and stop the urge to scratch

7. Etiology • Localized Itch Syndromes • Notalgia paresthetica • Itching or pain of upper mid back to scapula • Attributed to spinal nerve damage or entrapment • Family of 8 has been described • Skin biopsies show increases in sensory innervation • Tx by capsiacin cream or EMLA cream • Dermatographism • Skin changes are the sole result of skin trauma

8. Etiology • Fecal Contamination • Proven by patch test study done • Prompt appearance of symptoms and relief with washing believed to indicate an irritant effect • Seepage of liquid and mucus is important in causing symptoms • Coffee lowers resting pressures and may contribute • Anal inhibitory reflex is more pronounced • Rectal distention makes patients more prone to leak and soil

9. Etiology • Viral Infection • Condyloma acuminata • Papilloma virus infection • Anal intraepithelial neoplasia (AIN) • Herpes • Usually accompanied by pain • Molluscum contagiosum • HIV with secondary fungal infection • Fungal Infection • Dermatophytes • Trichophyton rubrum • Candida in the presence of steroids

10. Candidiasis

11. Etiology • Bacterial Infection • β hemolytic strep • Erythrasma • Corynebacterium • Wood’s light—coral pink • Cure with EES • Staph aureus • highly treatable with topical agents • Psoriasis • Don’t appear as typical because of maceration • Fluocinolone acetonide • Biopsy not reliable

12. Erythrasma—coral pink

13. Psoriasis

14. Etiology • Contact Dermatitis • Exematous inflammation characterized by erythema, scale, and vesicles • Topical anesthetics (procaine) • Topical antibiotics (neomycin) • Topical antiseptics • Topical antihistamines • Nickel • Avoidance of contact • Topical steroids • Avoid soaps, wipes • Use bath oils for cleaning

15. Etiology • Lichen Sclerosis • Chronic dz of unknown cause • Female/male 10:1 • White, atrophic, and wrinkled • Involvement of labia is characteristic • Biopsy needed to r/o SCC if not responding to treatment • Clobetasol propionate for 6-8 wks • Tacrolimus ointment

16. Lichen Sclerosis

17. Etiology—Food Factors • Coffee (2-3 cups) • Tea (4 cups) • Cola • Beer (less than 2 cans) • Chocolate • Tomato (ketchup) • Coffee • Alcohol • Peanuts • Chocolate • Milk products • Cola • Citrus

18. Etiology • Coexisting Anal Dz • Hemorrhoids • Prolapse may induce soiling • Skin tags may interfere with hygiene • Fissure • Fistula • Psychologic Factors • Anxiety • Stress • Fatigue • Personality • Coping skills • Obsessive compulsive disorder

19. Etiology • Steriod Induced Itching • Rebound phenomenon after withdrawal of steroids • Steroid addiction • Can lead to permanent deformity and dependence • Should be tapered • Skin Trauma • Diarrhea or frequent stools • Frequent wiping and maceration • Scratching while asleep

20. Etiology—Neoplasms • Perianal Paget’s • Rare • More than half of patients have itching, often longer than 3 months at presentation • Perianal Bowen’s • Intraepithelial squamous cell carcinoma in situ • Also rare • 60% presented with itching as main complaint

21. Bowen’s Disease

22. Etiology—Neoplasms • AIN • Sequel to HPV • Refers to premalignant change in area of dentate line and anal transition zone

23. Diagnosis • General classifications • Mass—inflammatory or neoplastic • Rash • Fissure—primary or secondary • Morphology • Crusts • Herpes genitalis • Scabies

24. Diagnosis • Papules • Venereal warts • Scabies • Molluscum contagiosum • Candidiasis • Syphilis • Diffuse erythema • Candidiasis • Trauma • Contact dermatitis • Fixed drug eruption

25. Diagnosis • Ulcers • Herpes genitalis • Syphilis • Trauma • Chancroid • Fixed drup eruption • Lymphogranuloma venereum • Tularemia • Behcet’s syndrome • Donovanosis (granuloma inguinale) • Candidiasis • Histoplasmosis • Mycobacterioses • Amebiasis • Gonorrhea • Trichomoniasis • Malignancy

26. Diagnosis • Miscellaneous findings • Linear tracks • Scabies • Reddish flecks • Crab louse excreta • Maculae ceruleae (sky-blue spots) • Crab lice • Nits • Crab lice • Hypertrophic • donovanosis

27. History and physical • History • Other skin conditions, allergies, other sites of involvement, asthma, urticaria • OTC or nonRx meds • Chemicals, clothes, laundry • Infections, colds, or diarrhea • Antibiotic use • Physical • Multiple sites--Check the groin! • Hyperpigmentation • Lichenification • Ulceration • Adenopathy • Defined margins

28. Labs • Aspiration • Swab • Bacterial and fungal cultures • Viral cultures • Skin scrapings • Punch biopsy

29. Treatment • Control seepage and fecal contamination • Fiber for loose stools • Immodium or Lomotil to lessen frequency or firm up stools • Questran can firm loose stools

30. Treatment • Removal of irritants—soaps, perfumes, dyes in clothes or wiping tissues, alcohol or witch-hazel containing agents, and moisture • Dove is a preferred bathing agent • Dilute white vinegar on a cotton ball is an alternate non-soapy cleaner • Burow’s solution is another nonirritating cleanser and can be used as an antibacterial soak for 5-15 min

31. Treatment • Hand held showers or bidets for cleaning perianal area • Use of a hair dryer to eliminate moisture • Athlete’s foot powder or barrier cream to lubricate and prevent maceration • Zeasorb—powder form • Avoid cornstarch—medium for yeast • Balneol—mineral oil based prep that’s portable

32. Treatment • Topical anesthetics, menthol, phenol, camphor can control symptoms • Topical steroids, antifungals,and antibacterials can be used • Pepper creams may eliminate need to scratch by providing a more painful stimulus

33. Treatment • Loose underwear that allows circulation • Laundry detergents without perfumes • May add chlorine bleach to keep bacterial counts down • Berwick’s dye—genetian violet and brilliant green • Has alcohol content and stings • Dry and follow with benzoin—lasts several days • Not for home application

34. Treatment • High potency steroids should only be used for a limited period of time • 4-8 weeks • Can then switch to low potency steroid with tapering to cessation • Prolonged use can cause skin atrophy • More notable with creams than ointments • Topical immunomodulators do not cause atrophy and may have antifungal properties • Silver sulfadiazine can promote re-epithelializtion when skin is denuded

35. Treatment • Anal tattooing • Intradermal and subcutaneous injection of • 10 mL 1 % methylene blue • 5 mL normal saline • 7.5 mL 0.25% bupivicaine with epi • 7.5 mL 0.5% lidocaine • 27 or 30 gauge needle to inject multiple sites to cover perianal involved skin up to the dentate line