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M62 Course – Cedar Court Hotel, Huddersfield 7 th April 2005 The Dermatologist and Pruritus Ani MJ Harries and CEM Griffiths Dermatology Centre, Hope Hospital,

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Presentation on theme: "M62 Course – Cedar Court Hotel, Huddersfield 7 th April 2005 The Dermatologist and Pruritus Ani MJ Harries and CEM Griffiths Dermatology Centre, Hope Hospital,"— Presentation transcript:

1 M62 Course – Cedar Court Hotel, Huddersfield 7 th April 2005 The Dermatologist and Pruritus Ani MJ Harries and CEM Griffiths Dermatology Centre, Hope Hospital, Manchester, UK

2 “An unpleasant cutaneous sensation that induces the desire to scratch the skin”

3 Itch-Scratch Cycle PRURITUS SCRATCHING DAMAGED PERIANAL SKIN

4 Yosipovitch et al. Lancet 2003; 361: Classification of Itch  Pruritoceptive itch  Originates in the skin  Neurogenic itch  Originates in the nervous system  Itch specific neuronal pathway (C-fibres and spinothalamic tracts)

5 Causes of Pruritus Ani  Anal pathology  Infections  Skin disease  Contact allergy  Underlying medical conditions  Idiopathic

6 Causes of Pruritus Ani  Anal pathology  Infections  Skin disease  Contact allergy  Underlying medical conditions  Idiopathic

7 Skin Disease  85% consecutive patients referred to a combined colorectal and dermatological clinic had an underlying dermatosis  Over half had a positive patch test “Patients with long-standing pruritus ani with no other symptoms to suggest colorectal pathology should be referred to a dermatologist for assessment and patch testing.” Dasan et al. Br J Surg 1999; 86:

8 Psoriasis  2% population  Approx. 1.2 million sufferers in the UK  Immune-mediated disease  Positive family history common

9 Psoriasis  Symmetrical  Extensor aspects  Elbows / knees  Scalp  Umbilicus  Natal cleft  44% perianal involvement Farber et al. Dermatologica 1974;148:1-18

10 Psoriasis - Perianal

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12 Where else to look?

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14 Lichen Planus  Idiopathic inflammatory disease of the skin and mucous membranes  Common sites  Flexor wrist  Anterior lower leg  Neck  Presacral area  75% oral involvement

15 Lichen Planus  Polygonal, violaceous, flat- topped papules  Wickham’s striae  Pruritus +++

16 Lichen Planus - Perianal

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18 Where else to look?

19

20 Lichen Sclerosis  Idiopathic inflammatory disease that preferentially affects the anogenital region  Hypopigmented and atrophic skin  Figure-of-eight distribution (women)  5% risk of SCC

21 Lichen Sclerosis - Perianal

22 Seborrheic Eczema  Link with sebum overproduction and the commensal yeast Malassezia furfur  Red-brown patches with “greasy” scale  Common sites  Scalp  Nasolabial folds  Central chest / back  Flexures

23 Where else to look?

24 Lichen Simplex – The Itch that rashes  Itching often localised to one site resulting in lichenification  Itch / scratch cycle develops  Common sites  Perineum  Scrotum / vulva  Posterior neck  Lateral lower legs

25 Lichen Simplex - Perianal

26 Allergic Contact Dermatitis  55 / 80 (69%) clinically relevant allergic reactions  38 of these reactions to medicaments or their constituents  Improvement or resolution of symptoms in ¾ patients with avoidance advice  Advise patch testing at an early stage Harrington et al. BMJ 1992; 305: 955

27 Eczema - Perianal

28 Patch Test  Common allergens placed into Finn chambers  35 common allergens tested in the BCDS standard series  Extra allergens tested in the perineal series  Type IV delayed hypersensitivity response

29 Patch Test – 0h

30 Patch Test – 48h

31 Patch Test – 96h  Grading system for reactions -Negative +/-Doubtful +Weak ++Strong +++ Very strong

32 Common Perianal Allergens  Local anaesthetics  Corticosteroids  Neomycin  Perfume  Preservatives  Antiseptics Goldsmith et al. Contact Dermatitis 1997; 36: 174-5

33 Pruritus Ani and Underlying Medical Conditions  Consider a “pruritus screen” if generalised itch is also present  Common causes include  Iron deficiency  Renal failure  Hepatic/ biliary disease  Malignancy  FBC  Ferritin / serum Fe / % sat / TIBC  ESR  U&E  LFT  TFT  Glucose  Calcium  Serum electrophoresis  CXR

34 Idiopathic Pruritus Ani  Faecal contamination  Difficulty in cleaning the area  Anal sphincter dysfunction Farouk et al. Br J Surg 1994; 81:  Dietary causes  Lumbosacral radiculopathy  16 / 18 (80%) lubosacral radiculopathy confirmed by N.C.S  Paravertebral injections of steroid / lignocaine resulted in reduced pruritus Cohen et al. J Am Acad Dermatol 2005; 52 :61-6

35 Treatment - General Advice  Wash after every B.O and twice a day  Avoid irritants  Keep the area dry  Wear cotton underwear  Keep bowels regular Alexander-Williams J. BMJ 1983;287:1528

36 Topical Steroids  Mild, moderate, potent and very potent  Treats inflammation  Break the itch-scratch cycle  As control is achieved the potency should be reduced  If not improving consider  ?Appropriate potency for condition  ?steroid allergy – Patch test  ?correct diagnosis - Biopsy

37 Other Treatments  Topical Capsaicin  Placebo controlled trial  0.006% capsaicin cream t.d.s for 4 weeks  31 / 44 (70%) responded Lysy et al. Gut 2003; 52: 1323 – 1326  Intradermal methylene blue injections  1% methylene blue / hydrocortisone / lignocaine  88% patients responded Botterill et al. Colorectal Dis 2002;4:144-6

38 Summary  Examine the entire skin surface including nails and mucous membranes  Consider patch testing early in management  Consider skin biopsy if any diagnostic doubt or if the condition is not responding to appropriate treatment


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