Presentation is loading. Please wait.

Presentation is loading. Please wait.

Perianal Dermatology/Puritis Ani A Corman Review Justin Blasberg, MD 9/22/05.

Similar presentations


Presentation on theme: "Perianal Dermatology/Puritis Ani A Corman Review Justin Blasberg, MD 9/22/05."— Presentation transcript:

1 Perianal Dermatology/Puritis Ani A Corman Review Justin Blasberg, MD 9/22/05

2 What to look forward to? Description of skin conditions affecting the perianal area Description of skin conditions affecting the perianal area Review of the differential diagnosis Review of the differential diagnosis Examples of common and uncommon findings Examples of common and uncommon findings Treatment of the relevant diseases Treatment of the relevant diseases

3 Classification of Skin Conditions Inflammatory Inflammatory Infectious Infectious Neoplastic Neoplastic

4 Inflammatory Pruritus ani Pruritus ani Psoriasis Psoriasis Lichen planus Lichen planus Lichen sclerosus et atrophicus Lichen sclerosus et atrophicus Atrophoderma Atrophoderma Contact (allergic) dermatitis Contact (allergic) dermatitis Seborrheic dermatitis Seborrheic dermatitis Radiodermatitis Radiodermatitis Behcet’s syndrome Behcet’s syndrome Lupus erythematosus Lupus erythematosus Dermatomyositis Dermatomyositis Scleroderma Scleroderma Erythema multiforme Erythema multiforme Familial benign chronic pemphigus (i.e. Hailey-Hailey) Familial benign chronic pemphigus (i.e. Hailey-Hailey) Pemphigus vulgaris Pemphigus vulgaris Cicatricial pemphigoid Cicatricial pemphigoid

5 Infectious Nonvenereal: Pilonidal sinus Pilonidal sinus Suppurative hidradenitis Suppurative hidradenitis Anorectal abscess and anal fistula Anorectal abscess and anal fistula Crohn’s disease Crohn’s disease TB TB Actinomycosis Actinomycosis Fournier’s gangrene Fournier’s gangrene Ecthyma gangrenosum Ecthyma gangrenosum Herpes Zoster Herpes Zoster Vaccinia Vaccinia Tinea cruris Tinea cruris Candidiasis Candidiasis “Deep” Mycoses “Deep” Mycoses Ambebiasis cutis Ambebiasis cutis Trichomoniasis Trichomoniasis Schistosomiasis cutis Schistosomiasis cutis Bilharziasis Bilharziasis Oxyuriasis (i.e. pinworm, enterobiasis) Oxyuriasis (i.e. pinworm, enterobiasis) Creeping eruption (i.e. larva migrans) Creeping eruption (i.e. larva migrans) Larva currens Larva currens Cimicosis (i.e. bedbug bites) Cimicosis (i.e. bedbug bites) Pediculosis Pediculosis Scabies Scabies

6 Infectious Venereal: Gonorrhea Gonorrhea Syphilis Syphilis Chancroid Chancroid Granuloma inguinale Granuloma inguinale Lymphogranuloma venereum (Chlamydia infection) Lymphogranuloma venereum (Chlamydia infection) Molluscum contagiosum Molluscum contagiosum Herpes genitalis Herpes genitalis Condylomata acuminate Condylomata acuminate

7 Neoplastic Acanthosis nigricans Acanthosis nigricans Leukoplakia Leukoplakia Mycosis fungoides Mycosis fungoides Leukemia cutis Leukemia cutis Basal cell carcinoma Basal cell carcinoma Squamous cell carcinoma Squamous cell carcinoma Malignant melanoma Malignant melanoma Bowen’s disease Bowen’s disease Extramammary Paget’s disease Extramammary Paget’s disease

8 Pruritus Ani “itching in the anal area” “itching in the anal area” Symptoms: Symptoms: Itching of anal and genital areas Itching of anal and genital areas Worsening at night Worsening at night May awaken the patient from sleep May awaken the patient from sleep Scratching with exacerbation of complaint Scratching with exacerbation of complaint Chronic itching can lead to atrophic or hypertrophic skin, with associated nodularity and scarring Chronic itching can lead to atrophic or hypertrophic skin, with associated nodularity and scarring

9 Pruritus Ani Differential Hemorrhoids Hemorrhoids Anal fissure Anal fissure Scarring from prior anal surgery Scarring from prior anal surgery Constipation/diarrhea Constipation/diarrhea Contact dermatitis Contact dermatitis Mycoses Mycoses Seborrhea Seborrhea Diabetes Diabetes Pinworm Pinworm Psoriasis Psoriasis Neurodermatitis Neurodermatitis

10 Why me, why now? Increased anal sphincter relaxation in response to rectal distension Increased anal sphincter relaxation in response to rectal distension Abnormal rectoanal inhibitory reflexes and a lower threshold for internal sphincter relaxation Abnormal rectoanal inhibitory reflexes and a lower threshold for internal sphincter relaxation

11 Evaluation Anoscopy and proctosigmoidoscopy Anoscopy and proctosigmoidoscopy Magnifying lens Magnifying lens Woods lamp Woods lamp Skin scrapings Skin scrapings Stool assessment? Stool assessment?

12 What you might see Marked edema with papillomatosis and nodularing resulting from chronic abrasion Marked edema with papillomatosis and nodularing resulting from chronic abrasion

13 Treatment Injections of local anesthetics, phenol, and alcohol Injections of local anesthetics, phenol, and alcohol Methylene blue Methylene blue Diet modification Diet modification Sterilization? Sterilization? Antibiotics? Antibiotics?

14 Psoriasis Chronic inflammatory disease of the skin Chronic inflammatory disease of the skin Characterized by rounded circumscribed erythematous dry scaling patches covered by grayish white or silvery white scales Characterized by rounded circumscribed erythematous dry scaling patches covered by grayish white or silvery white scales Predilection for scalp, nails, extensor surfaces or limbs, elbows, knees, and sacral regions Predilection for scalp, nails, extensor surfaces or limbs, elbows, knees, and sacral regions Butterfly distribution over the coccyx and sacrum Butterfly distribution over the coccyx and sacrum

15 Treatment Moisturizers and agents with salicylic acid Moisturizers and agents with salicylic acid Topical corticosteroids Topical corticosteroids Coal tar Coal tar Anthralin Anthralin Retinoid Retinoid Vitamin D3 derivatives Vitamin D3 derivatives Ultraviolet B light Ultraviolet B light PUVA treatment PUVA treatment Methotrexate and Cyclosporine Methotrexate and Cyclosporine

16 Lichen Planus Eruption of small, flat-topped papules with a distinct violaceous color and polypoid configuration Eruption of small, flat-topped papules with a distinct violaceous color and polypoid configuration Found in flexor surfaces, mucous membranes, genitalia, and perianal area Found in flexor surfaces, mucous membranes, genitalia, and perianal area Focal thickening of the granular layer, degeneration of the basement membrane and basal cells, and a bandlike lymphocytic infiltrate in the upper dermis Focal thickening of the granular layer, degeneration of the basement membrane and basal cells, and a bandlike lymphocytic infiltrate in the upper dermis Diagnosis made with skin biopsy Diagnosis made with skin biopsy Treatment with corticosteroids and occlusive dressings Treatment with corticosteroids and occlusive dressings

17 What you might see Moderate hyperkeratosis, thickening of the stratum granulosum, saw tooth configuration of rete ridges, and lymphocytic infiltration Moderate hyperkeratosis, thickening of the stratum granulosum, saw tooth configuration of rete ridges, and lymphocytic infiltration

18 Irritant and Contact Dermatitis Irritant: Nonallergic reaction following exposure to an irritating substance Irritant: Nonallergic reaction following exposure to an irritating substance Alkalis, acids, metal salts, dusts, gases, and hydrocarbons Alkalis, acids, metal salts, dusts, gases, and hydrocarbons Allergic (contact): Allergic sensitivity to a number of responsible agents, also known as hypersensitivity of the delayed type (cell mediated hypersensitivity) Allergic (contact): Allergic sensitivity to a number of responsible agents, also known as hypersensitivity of the delayed type (cell mediated hypersensitivity) Dyes, oils, resins, chemicals used on fabrics, cosmetics, insecticides Dyes, oils, resins, chemicals used on fabrics, cosmetics, insecticides

19 Radiodermatitis Secondary to radiotherapy of the rectum, anus, and prostate Secondary to radiotherapy of the rectum, anus, and prostate Cell mitosis is arrested; skin change results from the dosage of radiotherapy Cell mitosis is arrested; skin change results from the dosage of radiotherapy Erythema, edema, ulceration, and symptoms of burning, itching, or severe pain Erythema, edema, ulceration, and symptoms of burning, itching, or severe pain Treatment with oral Vitamin A 8000IU BID Treatment with oral Vitamin A 8000IU BID Hyperbaric O2 has also been found to be helpful Hyperbaric O2 has also been found to be helpful

20 What you might see Fibrosis of the dermis with sclerosis, atrophy of the epidermis, and absence of skin appendages Fibrosis of the dermis with sclerosis, atrophy of the epidermis, and absence of skin appendages

21 Pilonidal Sinus Common infective process occurring in the natal cleft and sacrococcygeal region Common infective process occurring in the natal cleft and sacrococcygeal region Affects young adults and teenagers Affects young adults and teenagers 3:1 male predominance 3:1 male predominance Epithelium lined sinus is usually found to contain hair Epithelium lined sinus is usually found to contain hair Sinus may become infected, usually after puberty, with drains openings overlying the coccyx and sacrum Sinus may become infected, usually after puberty, with drains openings overlying the coccyx and sacrum Infected abscess may extend to the perianal area that may be mistaken for an anal fistula Infected abscess may extend to the perianal area that may be mistaken for an anal fistula

22 Why me, why now? 2 Theories of formation: 2 Theories of formation: Failure of fusion in the embryo, with entrapment of hair follicles in the sacrococcygeal region Failure of fusion in the embryo, with entrapment of hair follicles in the sacrococcygeal region Result of trauma, with the introduction of hair shafts into the subdermal area Result of trauma, with the introduction of hair shafts into the subdermal area

23 Symptoms Pain, swelling, purulent drainage at and around the site of the pilonidal opening Pain, swelling, purulent drainage at and around the site of the pilonidal opening Typical appearance of an abscess may be evident Typical appearance of an abscess may be evident Fever and leukocytosis may be present Fever and leukocytosis may be present

24 What you might see Multiple openings overlying the sacrum and buttocks Multiple openings overlying the sacrum and buttocks

25 What you might see Indolent, granulating, nonhealing wound of a recurrent (persistent) pilonidal sinus Indolent, granulating, nonhealing wound of a recurrent (persistent) pilonidal sinus

26 Treatment Antibiotics? Antibiotics? Adjuvant to a surgical procedure Adjuvant to a surgical procedure I&D I&D Definitive therapy: Definitive therapy: Excision, excision with grafting or with an open wound to close secondarily, cryosurgery, and injection of sclerosing agents Excision, excision with grafting or with an open wound to close secondarily, cryosurgery, and injection of sclerosing agents

27 Tuberculosis Confused for Crohn’s, actinomycosis, anal fistula, colloid carcinoma, sarcoidosis, other skin conditions Confused for Crohn’s, actinomycosis, anal fistula, colloid carcinoma, sarcoidosis, other skin conditions Anal fistula is the most frequent presentation Anal fistula is the most frequent presentation Lesion appears as brownish red papule that can progress to an ulcerating plaque Lesion appears as brownish red papule that can progress to an ulcerating plaque Anal fissure in an unusual location that is slow to heal should raise the suspicion Anal fissure in an unusual location that is slow to heal should raise the suspicion Treatment: anti-TB drugs with resolve usually in 2 to 3 weeks Treatment: anti-TB drugs with resolve usually in 2 to 3 weeks

28 STD’s Gonorrhea Gonorrhea Chancroid Chancroid Chlamydia Chlamydia Herpes Simplex Herpes Simplex Syphilis: Syphilis: Chancre Chancre Condylomata lata Condylomata lata

29 What you might see Large perianal mucoid warty mass composed of smooth-surfaced lobules Large perianal mucoid warty mass composed of smooth-surfaced lobules

30 Neoplastic Premalignant Lesions Premalignant Lesions Acanthosis Nigricans-ominous association with abdominal cancer Acanthosis Nigricans-ominous association with abdominal cancer Affects face, neck, axillae, external genitalia, groin, inner thighs, umbilicus, and anus Affects face, neck, axillae, external genitalia, groin, inner thighs, umbilicus, and anus Grayish velvety thickening or roughening of the skin Grayish velvety thickening or roughening of the skin Epidermal papillomatosis, hyperkeratosis, and hyperpigmentation Epidermal papillomatosis, hyperkeratosis, and hyperpigmentation Treatment is directed to the primary malignant condition Treatment is directed to the primary malignant condition

31 Premalignant Lesions Leukoplakia Leukoplakia Whitish thickening of the mucous membrane epithelium occurring in patches of diverse size and shape Whitish thickening of the mucous membrane epithelium occurring in patches of diverse size and shape Seen in the anal canal Seen in the anal canal Associated with an increased risk of malignancy/epidermoid carcinoma Associated with an increased risk of malignancy/epidermoid carcinoma Symptoms of bleeding, discharge, and pruritic symptoms are the most common complaints Symptoms of bleeding, discharge, and pruritic symptoms are the most common complaints Hyperkeratosis and squamous metaplasia Hyperkeratosis and squamous metaplasia

32 Skin Cancer Basal Cell Carcinoma Basal Cell Carcinoma Most common cutaneous malignancy, extremely rare in the anal area Most common cutaneous malignancy, extremely rare in the anal area Tumors usually between 1-2 cm Tumors usually between 1-2 cm Presents with a lump or ulcer Presents with a lump or ulcer Bleeding, pain, pruritis, and discharge may be present Bleeding, pain, pruritis, and discharge may be present Treat with local excision and adequate margins Treat with local excision and adequate margins APR resection is performed for extensive or infiltrating tumors APR resection is performed for extensive or infiltrating tumors

33 What you might see Ulcerating tumor has a pearly border Ulcerating tumor has a pearly border

34 Skin Cancer Squamous Cell/Epidermoid carcinoma Squamous Cell/Epidermoid carcinoma Tumor appears superficial, discrete, and hard Tumor appears superficial, discrete, and hard Ulcerates with progression Ulcerates with progression Mets to regional lymph nodes can occur Mets to regional lymph nodes can occur Treat with wide local excision Treat with wide local excision

35 What you might see Ulcerating friable tumor is noted Ulcerating friable tumor is noted

36 Bowen’s disease Intraepidermal squamous cell carcinoma that spreads intraepidermally Intraepidermal squamous cell carcinoma that spreads intraepidermally Precursor to squamous cell carcinoma of the anus Precursor to squamous cell carcinoma of the anus Associated with HPV infection Associated with HPV infection Itching and burning, pain and bleeding Itching and burning, pain and bleeding Treatment wide local excision with frozen section to ensure adequate margins Treatment wide local excision with frozen section to ensure adequate margins

37 What you might see An indurated erythemato-squamous patch involving the perianal area An indurated erythemato-squamous patch involving the perianal area

38 Extramammary Paget’s Disease Large, round, clear-staining cells with large nuclei Large, round, clear-staining cells with large nuclei Symptoms of ulceration, discharge, pruritis, and occasionally bleeding and pain Symptoms of ulceration, discharge, pruritis, and occasionally bleeding and pain Treatment depends on the presence/absence or underlying invasive carcinoma Treatment depends on the presence/absence or underlying invasive carcinoma Use of retinoid, etretinate, may benefit when there is no invasive carcinoma Use of retinoid, etretinate, may benefit when there is no invasive carcinoma More infiltrating disease an APR may be needed, otherwise wide local excision with grafting should be adequate for noninvasive disease More infiltrating disease an APR may be needed, otherwise wide local excision with grafting should be adequate for noninvasive disease

39 What you might see Irregular but well- marginated erythematous erosive patch with slightly indurated edges Irregular but well- marginated erythematous erosive patch with slightly indurated edges

40 Extramammary Paget’s Disease Stage I-localized perianal disease without carcinoma-tx with wide local excision Stage I-localized perianal disease without carcinoma-tx with wide local excision Stage IIA-localized disease without underlying malignancy-tx with wide local excision Stage IIA-localized disease without underlying malignancy-tx with wide local excision Stage IIB-localized dx with associated anorectal carcinoma-tx with APR Stage IIB-localized dx with associated anorectal carcinoma-tx with APR Stage III-associated carcinomatous spread to regional lymph nodes-tx with APR plus chemoradiation, possible radical inguinal node dissection Stage III-associated carcinomatous spread to regional lymph nodes-tx with APR plus chemoradiation, possible radical inguinal node dissection Stage IV-distant mets-tx with standard palliative cancer management Stage IV-distant mets-tx with standard palliative cancer management


Download ppt "Perianal Dermatology/Puritis Ani A Corman Review Justin Blasberg, MD 9/22/05."

Similar presentations


Ads by Google