DIAGNOSIS:
The diagnosis of anal itching is evident in the questioning. We must use an etiology methodically, the essential pruritus is a diagnosis of exclusion.
Common, it affects middle-aged man than woman, with a sex ratio of 3.7.
The review must carefully find a local cause.
Disease duration is an important element: pruritus dating back more than a year is more likely to be essential.
The schedule of pruritus is important. There is often a nocturnal surge, social life preventing it from scratch in public.
We must seek possible transit disorders, medication orally and local.
The review of research excoriations: lichenification written off anus folds, perianal pigmentation, fecal soiling streaked, if the patient is scratching through her clothes.
Clinical examination research first dermatological lesions in the region that could explain the itching. More rarely, a proctology cause is sought. Intestinal diseases are rarely involved, most often Crohn’s disease, and are related to diarrhea or mucopurulent seeps.
As with any pruritus, in the absence of specific lesion, keep in mind the possibility of a general cause (anemia, Hodgkin’s disease, kidney failure, etc.), but this possibility is rarely here (see Itching ).
Diabetes can promote itching by repeated infections and especially sphincter dysfunction.
Dermatological causes are mostly infectious and inflammatory. Other causes are rare.
Recall that any acute genital or anal ulceration must seek a sexually transmitted infection (STI) and a chronic ulcer should she seek to cancer.
The use of colonoscopy and proctoscopy before an anal itching is exceptional. The proctologic examinations are requested by the proctologist after examination (anorectal manometry to study rectoanal inhibitory reflex, defecography).
ETIOLOGY:
Dermatological causes:
Infectious:
Candidiasis:
* Diagnosis:
Perianal candidiasis usually occurs after antibiotic therapy. Diabetes should also be sought. There is a perianal intertrigo up towards the buttocks, cleft and genitals. It is bright red, oozing with pustules on the outskirts and desquamative collar. The mycological samples are not necessary. If they are realized, they will highlight the Candida albicans.
Avoid maceration and the use of acid products.
* Treatment:
Treatment is twice daily application (econazole, Pevaryl® fluid solution for reaching the anus and the seat for 8 to 21 days usually, eventually cream to the skin lesions, powder if the lesions are very wet) or daily ( ketoconazole, Kétoderm® cream) topical antifungal azole after washing and decontamination of the digestive home with an oral antifungal (Nystatin oral tablet Mycostatin®, 2 cp 3 times a day for fifteen days to three weeks).
Towels (towels) must be personal.
Strep Anite:
* Diagnosis:
Strep anusitis usually occurs in children under 10 years. It combines the itching anal pain and painful defecation.Clinically, erosive anusitis observed associated with a well defined anal erythema. More rarely, there may be a vulvovaginitis in young girls. It is usually due to a bêtahémolytique streptococcus group A.
* Treatment:
The treatment involves the application of a topical antibiotic for a period of five to seven days maximum (eg fusidic acid cream Fucidine® one to two applications per day after the toilet) associated with systemic antibiotics (amoxicillin, Clamoxyl® 1 g 3 times a day for adults for seven days).
Dermatophytosis:
* Diagnosis:
Dermatophytosis carries an array of perianal intertrigo erythematosus, although limited, with vesicles along without desquamative collar.
The center is often pale, swarthy, with an active border. We must look for remote satellite lesions and between the toes.
Dermatophytes involved are usually anthropophilic dermatophytes.
* Treatment:
The treatment uses the same principles as for candidiasis. In case of extensive lesions, multifocal, chronic, recurrent or resistant to local treatment well conducted, a general treatment may be needed in combination with local treatment better after positive income mycological samples: terbinafine, Lamisil® 1 cp / d in the course of a meal for two weeks to three weeks.
Erythrasma:
* Diagnosis:
One realizes erythrasma intertrigo very limited, buff, without central healing aspect, without pustules or vesicles. The Wood’s light examination revealed a coral red fluorescence. It is due to infection with Corynebacterium minutissimum.
* Treatment:
The treatment is topical, erythromycin (erythromycin cutaneous solution, 1 time a day for two weeks) or topical azoles (ketoconazole, Kétoderm® cream, on the same terms as candidiasis).
Ectoparasitosis:
* Diagnosis:
The phthiriasis (crabs) is a sexually transmitted infection accessory, often linked to prostitution or poor hygiene conditions (indirect contamination bedding and towels possible). There nits and adult parasites (small gray masses) on the pubic hair, visible to the naked eye, typically a slaty color of the abdomen. Another hair reached (eyebrows, chest hair, for example) should be sought.
* Treatment:
Treatment consists of shaving pubic hair, typically applying a powder to slip Aphtiria® (anymore) for 24 hours or a topical pest (malathion lotion kind Prioderm® lotion) and washing the bedding and underwear at 70 °.
The treatment can be repeated eight days later.
The partners are also treated.
Scabies can also be a cause of anal itching (see Itching).
Sexually transmitted infections:
They affect women here and homo or bisexual man.
The anal gonorrhea may be few symptoms, sometimes with a discreet but intense itching flow (see Urethral discharge). The syphilitic chancre is sometimes responsible pruritus (see ulceration of the oral and genital mucosa).Genital herpes can affect the anal area and be accompanied by pruritus (itching cf.).
Inflammatory:
Inverse psoriasis:
* Diagnosis:
Inverse psoriasis is a common cause of pruritus ani. It carries a bright red chronic intertrigo, although limited, little or no scaly, extending from the anal margin to cleft, asymmetrical and fissured. Other psoriasis locations allow the diagnosis.
* Treatment:
In this localization, treatment includes grooming and applying a topical corticosteroid betamethasone kind Diprosone® cream (1 time per day for seven days and then gradually decline).
Irritant dermatitis summer:
In summer, especially after prolonged physical activity, think to summer anal pruritus, irritant dermatitis due to maceration, sweat, mechanical friction buttocks and unable to wash momentarily. It yields to soaping and careful drying.
Contact dermatitis:
* Diagnosis:
It achieves a clinical picture of eczema. It complicates usually an underlying pathology (hemorrhoids, dermatitis) and is linked to topical medications used (eg for hemorrhoids or skin disease: caine anesthetics of the group, neomycin, Peru balsam, antihistamines) . It is rarely due to other local causes (toilet paper, soap, scented products, textile dyes).
* Treatment:
Discontinuation of topical awareness, the momentary application of topical corticosteroids like betamethasone Diprosone® is usually effective.
Pay attention to pruritus relapses after application of topical corticosteroids for inverse psoriasis or contact eczema creating a steroid rosacea array on numerous occasions of corticosteroid treatment.
Rarer:
Rarely, Paget’s disease or Bowen (érythématosquameuses chronic injury of the region) may be involved. We must entrust the patient to a specialist for biopsy and possibly surgery.
Lichen performs an indurated plaque, erythematous, atrophic and itchy, sometimes associated with genital involvement. Treatment consists of topical steroids, with monitoring by the specialist.
The Hailey-Hailey disease, bullous dermatoses are rare contingencies.
Intestinal causes:
Enterobiasis:
The pinworm preferentially affects children with night recrudescence pruritus, alarm clocks and cries in the offspring.The worms can be seen with the naked eye or scotch-test.
Treatment is based on a single dose tablet flubendazol (Fluvermal®) to repeat a month later. It must also treat the family, disinfect bedding and linen.
Proctologic causes:
The skin tags, fissures, fistulas, hemorrhoidal prolapse can be a cause of pruritus ani by seepage and dirt. A neighbor clinical appearance may be related to the achievement of perianal Crohn’s disease.
There may well a painful spasm of the sphincter after defecation, revealing a sentinel hemorrhoid of fissure or fistula.
More rarely, anal cancer is diagnosed on clinical examination. Involuntary loss of stool can cause anal itching, indicative of fecal incontinence, rectal prolapse or a benign tumor such angiofibrome or anal papilloma. The patient must be given to the proctologist.
Colic tumors (villous) were incriminated.
Chronic diarrhea (Crohn’s disease, ulcerative colitis, etc.) may cause local irritation by stools, itching causes.
Drugs and foods:
Colchicine and quinidine have been implicated.
Tomatoes, caffeine sodas, beer, dairy products spices and lemon were also questioned.
Gynecological causes:
Pruritus ani may rarely be associated with vaginal, uterine cancer in women. There are clinical call points.
The treatment of pruritus ani is here etiological and symptomatic first.
Essential pruritus ani:
With no obvious cause, anal itching is said essential. Toilet habits or excessive fecal soiling linked to anal dyskinesia may be involved.
Psychiatric causes are sometimes seen (personality disorders, depression, sexuality, psychotic disorders) but must not be mentioned as first line.
The quality of the doctor-patient relationship is essential here.
Treatment is symptomatic.
TREATMENT:
It is symptomatic and associated with the etiological treatment given alone or in the absence of due highlighted.
Hygiene care is needed:
– Fresh towels twice daily, after each bowel movement, by washing with a synthetic detergent and rinse bidet or soft (Lipikar syndet® example). Drying should be careful dabbing;
– Port of cotton underwear, loose, to avoid maceration.
Also avoid irritating foods (coffee, tea, chocolate, mustard, spices) and aggravating drugs to the extent possible (colchicine, quinidiques).
The local treatment must first avoid the application of potentially irritating topical.
Gel can be applied calamine kind Pruriced® gel for example once or twice a day.
Eventually, we can propose the application of a weak topical corticosteroid (hydrocortisone cream) once daily on days (maximum eight) associated with taking an antihistamine (loratadine, Clarityne® 1 morning or hydroxyzine Atarax® 25 mg in the evening as sedative).