Dermatologic concepts and management of pruritus ani

Dermatologic

Concepts of Pruritus

JOHN L. FROMER,

M.D. (By Znvitation),

From tbe Department PJ Allergy and Dermatology, Lube>. Clinic, Boston, Massachusetts.

Tbe

Boston,

iZlas.sachusetts

pruritus ani (about 45 per cent). The remainder of our patients suffer from systemic diseases incIuding diabetes, Iymphoblastomas, liver disease, parasites, kidney disease or cancer elsewhere than the recta1 area, associated with pruritus ani. (TabIe I.)

IV spite

of the advances in our knowledge and management of dermatitis, the treatment of patients with pruritus ani is a difhcult and, at times, a bafFIing problem. The purpose of this paper is to review some of the basic dermatologic concepts reIated to the production of dermatitis with its attendant pruritus. A system of treatment will aIso be proposed. Many authors have reviewed Classijkation. the etiology and management of pruritus ani and most of the recent ideas concerning this subject have been reported by Swinton,’ TureIl,2 Becker3 and others. The author has worked aIongside Swinton in the management of these problems and agrees wholehearted13 with his approach to the subject. These reviews mention the known causes which incIude local and systemic diseases resulting in pruritus ani. Roughly 25 per cent of our patients at the Lahey CIinic have anorecta1 problems which are best dealt with by the proctoIogist, and the pruritus improved by the necessary surgical measures so instituted. This surgery is directed at the correction of obvious anorectal disorders. About 20 per cent of our patients have other dermatologic diseases which are readiIy manifest when the entire cutaneous surface is exposed. Psoriasis, seborrheic dermatitis, mycologic and bacteria1 dermatitis, and atopIc dermatitis account for most of the dermatoIogic conditions which involve the anogenital area. A fair number of patients are seen with lichen sclerosus et atrophicans which is considered by some to be a variant of lichen planus, and by others a variant of kraurosis. It is usually accompanied by intense itching but there are other manifestations of the disease chiefly on the shoulders, wrists and forearms which readily help to make the diagnosis. Perhaps the most resistant patients as far as management is concerned are those with so-called essentia1

I

and Management Ani

TABLE I CLASSIFICATION OF PRURITCS AN1 Surgical

(25 7f) PapiIIitis Cryptitis Skin tags InternaI hemorrhoids NeopIasms

Fissures Fist&s Draining sinuses UIcers Mucosal prolapse

Dermatologic (65 YO,) Psoriasis Seborrheic dermatitis Bacteria1 dermatitis Mycotic dermatitis

Lichen scIerosus Syphilis Contact dermatitis EssentiaI (idiopathic)

(45 “/$)

General (IoyO) Allergy: “ Gaines” Hygienic pads Deodorants Foods

Diabetes--liver Parasites Lymphoma Antibiotics

Histopatbolog,y. Many authors have referred to a wet and dry type of pruritus ani. To the dermatoIogist, this distinction is only a matter of degree in the same type of process. Most dermatoIogists consider that the terms dermatitis and eczema may be used interchangeabIy. Eczema is described by Lever4 as an inflammation of the skin based on its aIIergic response to a variety of agents such as chemicaIs, proteins, bacteria and fungi. The exciting aIIergen may act on the skin either from the outside (epiderma1 sensitization) or from the inside (vascular sensitization). Dermatitis, or eczema, may be acute, subacute or chronic. White the clinica picture is characterized by poIymorphism of the eruption, usuaIIy the skin is Iichenified, or thickened and purplish-hued, with or without fissures, scaIing or crusting in the anogenital area. In the acute phase, how&5

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Fromer ever, actuaI weeping or a so-caIIed wet pruritus ani may be seen. HistoIogicaIIy, in acute dermatitis the epidermis presents interceIIuIar edema (spongiosis), intraceIIuIar edema and microscopic intraepiderma1 vesicuIation.

FIG. I. ReIative density of itching points in male anogenita1 region. (Modified from Shapiro and Rothman, Gastroenterology,3: 155-168, 1945.)

In areas of more severe intraceIIuIar edema, the ceIIs undergo Iiquefaction necrosis and disintegrate. According to some authors, the areas of epiderma1 Iiquefaction necrosis attract fIuid from the corium because of a DhvsicaI-chemicaI force which they possess. The’ p&sage of tissue fluid through this type of damaged epidermis is then an easy matter, resuIting in weeping cIinicaIIv. It is rare to see vesicIes cIinicaIIv in the immediate periana1 zone Iimited to 3 to 4 cm. of the anus. On the gIabrous skin beyond this zone, vesicIes are not uncommonIy seen foIIowing the use of some sensitizing preparation. In the dry form of pruritus ani, the histologic features of chronic dermatitis are seen. Hisis a marked acanthosis toIogicaIIy, there (thickening) with eIongation of the rete ridges. There are scattered areas of hyperkeratoses with areas of parakeratoses (abnormal retention of nucIei). OnIv sIight intraceIIuIar edema may be present in the epidermis and vesicIe formation is absent. In the upper corium there is a perivascuIar infiItration composed of a muItipIicity of ceIIs which incIudes lymphocytes for the most Dart. but the number of eosinophiIs, histiocyies and fibrobIasts may be considerabIe. Neutrophils are usuaIIy absent. The number of caDiIIaries is increased and their endotheIia1 celis may show sweIIing and proIiferation. CIinicaIIy this is accompanied by the itching of “dry lichenification.” It has been produced experimentaIIy anywhere in the body by ingenious “scratching machines” which resuits in a cIinica1 and histoIogic picture of the naturaIIy occurring condition. ”

Essential

(Idiopathic)

Pruritus

Ani.

On

carefu1 examination of patients ivith essential of the canals of the pruritus ani, dermatitis externa1 ear (another orifice) may occasionally be found. Not infrequently, too, lichenified dermatitis, sharply circumscribed and superficia1 in appearance, may be noticed on the back of the neck and extending for a short distance into the hairline of the occiput. This is referred to as lichen chronicus simpIex or neurodermatitis. The characteristics of essentia1 (idiopathic) pruritus ani are as foIIows: (I) usuaIIy dry, fissured and Iichenified; (2) may (3) occurs in “weep” if recentIy eczematized; -tense, perfectionistic individuaIs and (4) is associated with irritabIe bowe1, neurodermatitis eIsewhere, otitis externa, food aIIergy and psychosomatic determinants. In addition to the anal region, the areas most frequentIy invoIved in essentia1 pruritus ani are probabIy the vuIva in femaIes and the scrotum in maIes, either by extension of the disorder or onset of the actua1 disease de nom A simpIe extension of the horizon of the proctoIogist to areas other than the arogeritaI region wiI1 often help him to characterize the condition cIinicaIIy. PRURITUS

Any consideration of pruritus ani must incIude a discussion of pruritus. In the modern concept of itching, the dermatologist prefers to consider pruritus as an aItered pain sensation. It is of interest that stimujation of cold spots in the skin wiI1 eIicit the sensation of cold no matter how they are stimuIated. Pain spots in the skin, however, can be stimuIated by various technics to cause an itching sensation. This expIains why various “ non-specific ” stimuli which represent different forms of energy may yieId an itch response.5 As noted in Figure I, the density of itching points in the anogenita1 area of the male is markedly increased within the first I to 2 cm. of periar.aI skin, Itching is absent if the epidermis is denuded. Agents which can cause the disappearance of pain wil1 aIso affect itching in the same way. When pain returns, the pruritus returns with it.‘j It has also been noted that centra1 points of itching such as may occur in the rectum can be foIlowed by waves of itching which extend to other parts of the body. Scratching is a norma reflex response to the itch sensation and it is diffrcuIt to criticize a

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DermatoIogic

Concepts

patient for scratching. The intolerable, weak pain which MY call itch is so unpIeasant that the patient tries to convert it to a strong pain by the process of scratching. Itching disappears when strong pain is substituted. Strong pain often is more endurable, at least temporarily, than the unpleasant sensation of itching. Scratching damages the skin, however, and this prevents natural healing and is followed by other effects which prolong dermatitis. It may be said at this point that none of the local anesthetics or antihistaminics per se show any ability to penetrate when applied to the normal or injured skin, and so do not alter the pain or itch.‘,* Moreover, fifty-four topical antipruritic preparations commonly prescribed were found to have no effect on experimentally produced histamine pruritus in man.9 Itching may be present without any abnormality in the skin of the perianal area. The itch threshold is lower after psychic trauma and the large emotional element so induced makes these patients difficult to manage.“’ Factors

IVhicb

May

Maintain

of Pruritus

Ani

irritation. A knowledge of these facts \vill give further insight into the difficult problem which confronts the practitioner in the management of pruritus ani. It has been my experience that patients with this disorder have “been about” and have seen men competent to deal \vith this entity. There must be some explanation for the chronicity and continued discomfort suffered by the patient with this disorder. Sensitization by Topical Agents. The actual sensitization of the damaged skin is one of the most constant and persistent reasons for the continuation of pruritus ani. Sensitization dermatitis or dermatitis therapeutica is a well established disorder both from the clinical and the experimental standpoint. In recent years, however, the introduction of newer drugs for topical appIication has brought this fact more forcibly to our attention. The widespread use of the sulfonamides for the treatment of superficial pyogenic infections of the skin showed early in the past decade the high “sensitizing This \yas index” of this class of compounds. closely followed by such sensitizing prcparations as penicillin, streptomycin, the “caines” and certain antihistaminics applied locally.” In controlIed clinical studies Perry’” and Baldridge’” were not able to demonstrate any antipruritic or anti-infIammatory activity ol several active antihistaminic ointments that could not be explained by the use of the ointment base without the addition of antihistaminics. Likewise, other clinical studies’” showed that the efficacy- of various local anesthetic agents has in no instance been proved on the basis of controlled work. It has been shown that the penetration of these agents through the unbroken skin in amounts suff~cient to have any local anesthetic effect is virtually impossible. The explanation is that the skin is too effective a barrier to allow for sufficient transfer of molecules of the chemical anesthetic to dissociate from the vehicle. This differs from the response of mucous membrane in which the action of local anesthetic agents is effective, for example, in internal hemorrhoids. Transepidermai absorption of various substances including electrolytes, lipid soluble compounds, hormones, vitamins, heavy metals and their salts as well as man\ other substances, has been studied by various technics. It is hoped that further information regarding transport through epidermal cells may be forthcoming with the use of isotopes and

Dermatitis

Pillsbury” has summarized the important factors which help to maintain dermatitis and which may account for the lack of improvement in these patients. It is well to remember, for example, that probabIy there are multiple etiologic factors which account either for the onset or the continuation of pruritus ani. Does the patient have contact dermatitis, seborrheic dermatitis or is he an atopic individuaI? Is he emotionally unstable, with the appearance of localized neurodermatitis either soIeIy in the perianal area or accompanied by lesions of lichenified neurodermatitis elsewhere? Are there mycotic and bacterial elements that have altered the clinical picture? Has the dermatitis been continued because of ingested or inhaIed substances in an already atopic or allergic individual? It is well to remember the axiom, “An irritant applied to an irritated tissue can resuIt only in more irritation.” In the “factorial analysis” of an itching dermatitisl” causa1 concepts are considered, such as production of epiderma1 sensitization during treatment, bacterial invasion of the dermatitic skin, change in the hydrogen ion concentration of the eczematous skin, mechanical brocking of sweat ducts and many other changing phenomena associated with skin 807

Fromer radiographic technics, histochemistry and other methods. It is of interest that the pH of normaI skin is usuaIIy on the acid side, varying from 4 to 7, chiefly being between 4.2 and 5.6. EarIier work in this fieId was confirmed by BIank16 who used gIass eIectrodes and obtained precise and reIiabIe potentiometric measurements on the arms of normaI maIes, femaIes and chiIdren. In the diseased or inflamed skin, however, the hydrogen ion concentration is altered toward the aIkaIine side and reverts to the acid side when the inflammatory process subsides. Anderson17 reported that the hydrogen ion concentration of the skin in atopic eczema is raised to the aIkaIine side. Likewise, Schmidls found a considerabIe shift of the hydrogen ion concentration of the skin surface sweat to the aIkaIine side in cases of eczema and seborrheic dermatitis. Patients with these disorders are subject to bacteria1 infection. AIthough fungi grow best in the Iaboratory in Sabouraud’s medium (pH 4.9), Pereiro Miguenslg found that moniIia1 infections favor a pH cIoser to norma (pH 7). Bacterial Flora. In this connection the roIe of bacteria in the continuation of chronic dermatitis is often overIooked. PiIIsburyzO has shown that the inflamed skin has reduced antibacteria powers against pathogenic organisms. This is true whether the dermatitis has an external or interna causation. Within a few days to weeks, the bacteria1 ffora of eczematous skin changes markedly. These changes permit the growth and recovery of a coaguIase positive hemoIytic StaphyIococcus aureus two to three times as frequentIy as from norma skin and recovery of a beta hemoIytic streptococcus at Ieast twice as frequentIy as from norma skin, incIuding the isolation of LancefieId group A streptococcus in some 15 to 20 per cent of cases. This organism aImost never is found on the norma skin other than as an occasional contaminant. FortunateIy, frank pustuIes, ceIIuIitis and Iymphangitis associated with chronic dermatitis are rareIy seen in pruritus ani, but these pathogenic and potentiaIIy pathogenic organisms, aIthough abiding in a harmless fashion on the skin, may be producing skin damage in a manner not yet understood. It is beIieved that after a period of time many individuals become sensitized to these abnormal bacteria and particuIarIy to the staphylococcus. This sensitization or aIIergy to the bacteria can produce 808

the same type of low grade inflammatory response in the skin, which is seen in the tuberculin or the Trichophyton reaction. It is simiIar to the reaction seen forty-eight hours foIlowing the introduction of any bacteria1 antigen into the skin of a sensitized individua1. The demonstration of specific hypersensitivity by extracts of either autogenous or stock bacteria1 antigens is diffIcuIt to evaIuate cIinicaIIy with our present technics. Likewise, the cIinica1 resuIts of the use of autogenous or stock bacteria1 extracts in treatment is not easiIy measurabIe with any degree of scientific accuracy. NevertheIess, bacteria1 extracts or vaccines and other nonspecific agents (proteins-typhoid) are often useful in chronic dermatitis. Pyodermia of the skin eIsewhere than in the anogenita1 area is readiIy controIIed with broad spectrum antibiotics. Since pruritus of this area is frequentIy seen after Iong courses of antibiotics given for other conditions, it is unwise to use this modaIity for any extended time in pruritus ani. NevertheIess, the parentera administration of the antibacteria agent is probabIy superior to any type of IocaI appIication of these substances. In addition to the epiderma1 Allergy. sensitization produced in some patients by the direct appIication of sensitizing drugs, certain principIes of aIIergy appIy to the management of a chronic eczematous process. The pathoIogic and cIinica1 pictures and the response of the epidermis and dermis to injury are very much the same regardIess of the agent invoIved. Even though pathogenic fungi or .bacteria can be demonstrated in the area, the skin response is that of eczema. This is aIso true when ingested proteins, drugs, antibiotics, simpIe chemicaIs and other antigens arrive and react at the sensitized site-the end resuIt is stiI1 eczema. AnogenitaI itching may be seen as a manifestation of certain other allergic responses. During the routine administration of poIIen extracts a reaction may suddenIy deveIop in the patient with hay fever soon after the injection of the offending pollen; usuaIIy there is a brief period of sneezing, conjunctivitis or rhinorrhea. If the reaction is more severe, however, urticaria and pruritus appear accompanied by severe anogenita1 itching. This can usuaIIy be controIIed by the prompt use of epinephrine. The reasons for the IocaIization of pruritus in this reaction are not known. A similar interesting reaction

DermatoIogic

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of Pruritus

Ani

are not good criteria for investigating clermal sensitivity to foods in pruritus ani. Trial diets, food diaries and a high index of suspicion to known allergenic foods are much more practical approaches to this problem. Sweat Retention Syndrome. As the puzzle of the continuation of chronic itching dermatitis continues to unfold, certain other investigations in the past decade are cvorthy of documentation. Mechanica blockage of sweat ducts as a factor in dermatitis were studied by dermatologists as a result of the diseases of sweat glands seen in miliaria during World War II in troops in the Southwest Pacific.22~24 Following the initial studies it \vas demonstrated that complete loss of sweating followed a variety of minor or insignificant injuries to the skin. These included, for example, moderate exposure to ultraviolet light, patch tests with soap solution and various other agents, and application of adhesive tape or continuous wet compresses. If a patch of skin will not sweat for a period of two to four weeks after application of adhesive tape, is it any wonder that the same phenomenon will exist following an inflammatory process of the skin? In a number of common skin disorders-atopic dermatitis, contact dermatitis, fungous infections and others-this function is diminished or complete loss of sweating may exist. It is possible that obstruction of the sweat mechanism, with retention of the secretion or escape into the layer of the skin, may play a role in the maintenance of acute or chronic dermatitis. Moreover, since the sweat of some patients has been shown to be urticariogenic, the retention of this irritant-containing material can produce whealing and itching at the site.251”” Psychosomatic Determinants. The constant annoyance of any. eruption which is associated with pruritus is d&cult enough for the patient to tolerate; there seems to be something especially annoying about anogenital pruritus. Much has been written about the psychosomatic influence upon this disorder. In many instances it is difhcult to tell which is the cart and which the horse, although, in my opinion, these influences are contributory and never causal. Some deny the nervous influence on the disease; others believe that none but the psychiatrist shouId manage anogenital itching. The experience of different authors will depend on the type of material seen. Anxiety and tension play an important role in the continua-

may also be seen occasionally in the individua1 who is allergic to poison ivy. With routine oral desensitization using an oleoresin of poison ivy, a reaction consisting of severe pruritus ani may occur which is the first sign of the limit of tolerance of oral dosage for that particuIar patient. This is also true in ragweed oil oral desensitization and may explain the mechanism of production of anogenital pruritus in patients taking extended courses of antibiotics. Patients with generalized penicillin reactions complain bitterly of anogenital pruritus. A patient in whom an allergic reaction to one preparation has already deveIoped is more susceptible to sensitization to other preparaReactions to the same “family” of tions. drugs are, of course, more readiIy produced; for instance, the crossed sensitivity of a patient to a group of drugs such as the “caines.” But the sensitization may go much further than this. Sensitivities to unreIated substances may develop and it is said that “broadening of the allergic base” has occurred.” Atopic individuals (asthma, hay fever, infantiIe and atopic eczema) are born with the capacity for sensitization by endogenous or exogenous routes. An alarming number of anaphylactic deaths due to penicillin, for exampIe, have occurred in this Penicillin reactions in group of individuals. non-atopic individuals, although troublesome and at times severe, are rarely fata1. Normal individuals can readiIy be sensitized by the external application of various substances. The percentage of positiveIy sensitized individuals varies with the substance. Almost 70 per cent of the normal population can be sensitized with poison ivy extract. Sulfonamides, penicillin and some antrhistaminics may produce sensitization as high as IO per cent. Some patients seem to have a permanent immunity and can never be sensitized regardIess of the number of exposures to a given substance. During a severe exacerbation of dermatitis, the range of contact hypersensitivity may suddenly increase. In patients of this type the application of relatively harmless local preparations may produce reactions. Some of these agents may have been used previously by the patient without any untoward reaction. Moreover, it is not an uncommon clinical finding that an area of skin so sensitized to a chemica1 compound, or in which secondary infection has developed, may react to ingestion of a particular food.21 Intracutaneous or scratch tests with foods in these cases

809

Fromer use of IocaI anesthetics, general anesthetics and sedatives. If IocaI anesthetics applied to the intact skin are to function, enough of the anesthetic agent must penetrate the skin to the sensory nerve endings to aIter their abiIity to receive or transmit the stimuIus. As previousIy mentioned, it is doubtfu1 whether IocaI anesthetics can penetrate intact skin very rapidIy. They wiI1 penetrate broken skin or mucous membranes more rapidIy. Again, Iike antihistaminics, they have a high index of sensitization and this would aIIergicaIIy traumatize the skin. Actually our greatest success in the periphera1 contro1 of itching is obtained by substitution of another stimuIus. This is what happens when the patient scratches and excoriates the periana1 area. He simpIy substitutes a pain stimuIus which is more toIerabIe than the pruritus. Another substitution phenomenon is the IocaI application and action of the wet dressing and Iotions. These alter the temperature of the skin and this substitutes the sensation of heat or coId for the itch sensations and, temporariIy at least, relieves the itching. The temperature of the appIication is very important. As a rule, even a smaI1 eIevation in temperature may aggravate pruritus; for example, a patient’s itching may increase when he enters a warm room. A very hot dressing may temporarily increase itching but subsequentIy relieve it. If the dressing is hot enough to be painfu1, this aIso is a substitution of pain for itching. A decrease in the temperature of the cutaneous surface usuaIIy reIieves itching and much of the external therapy of the skin is directed toward cooling the cutaneous surface. Wet Dressings. The rate at which heat from the skin is Iost to the wet appIication wiI1 depend on four properties of the wet dressing: (I) the Iiquid used, (2) the temperature of the Iiquid, (3) the amount of Iiquid per unit area of skin, and (4) the rate of evaporation from the surface of the liquid. Water is probably the most commonIy used liquid for the wet dressing and the most efhcient because it has the highest heat capacity of any liquid, according to BIank.28 When the two methodsthe cIosed compress of water and soaking in a tub-are compared, the major difference is the amount of water used per unit area of skin. In generaI, since there is considerable water in a soak, the skin wiI1 be cooIed satisfactoriIy. However, one must consider that heat can be

tion of the scratch-itch-scratch cycIe in our patients who have had exceIIent management for pruritus ani before coming to the Lahey CIinic. These comprise the buIk of patients with so-called essential pruritus ani. In most of these patients it is possibIe in severa interviews to aIIow them to “ventitate” openIy. AIthough time-consuming, it is important to discover earIy in the course whether expert psychiatric help wiII be necessary. Furthermore, it is necessary to estabIish good contact with the patient when the need for this type of consuttation arises. Positive reassurance and a kindIy attitude heIp most patients who have a situationaI-emotiona problem. Others who show more serious psychosomatic determinants associated with pruritus ani are best Ieft to the expert guidance of a psychiatrist who has some famiIiarity with skin problems. TREATMENT

The ultimate goa of therapy is remova of causes the cause of itching. z The numerous mentioned in the introductory portion of this paper shouId be searched for and eIiminated. Freed from a11 extraneous encumbrances, the objectives of therapy in pruritus ani can be Iisted under three headings: (I) relieve itching; (2) acceIerate healing, and (3) aIIow natural healing without trauma due to physical, chemica1, aIIergic or microbiologic agents. In discussing possibIe mechanisms for the reIief of itching, the first consideration couId be the remova of the stimuIus. BIankz8 beIieves that the best treatment for the reIief of a symptom is the remova of the factor or factors that cause that symptom. This is seldom possibIe when one attempts to reIieve itching. It is rare that the stimulus is known. The patient who itches after wearing a woo1 sweater or dermatitis which develops after a baby wears a new wooIen snow suit is easily managed by removing the offending agent, which is fairIy easiIy recognized. When itching results from bites of parasites, the stimuIus is removed indirectly by ridding the patient of parasites. One can only speculate that perhaps histamine reIease may be the cause of the pruritus. It is not reIieved by local application of antihistaminic preparations. AIso, the sensory reception, transmission or perception of the stimuIus couId be aItered by either peripheral or central attack on the problem. This introduces, again, the subject of the 810

DermatoIogic

Concepts

of Pruritus

Ani

Based on these principles, an effective lotion is as follo\vs: menthol 0.1 to 0.2, hesachlorophenol o. I, glycerol 10.0 to r4.o isoprop?;l alcohol (99 per cent) 20 to 30 cc., eater idistilled) qs. ad 100 cc.* This lotion can be used on subacute and chronic dermatoses. It can be used after the Hurst day or tno of vvet dressings for acuteI> inflamed pruritus ani. If fissures are present, some stinging ancl smarting may accompany the use of the lotion because of the presence of alcohol and glycerol. If the patient is ndvised about this, there will be no objection. Since phenol is a toxic agent its use locall! should be carefully controllecl. Ointments. In addition to soaks, compresses and lotions which have an antipruritic effect because of their cooling properties, ointments recommended for pruritus ani have heen legion. Aside from empiric usage, however, their effectiveness if present in individual cases is hard to explain. Ointments, lvhen used in this condition, should be limited to one of several actions: (I) antibacterial agents, (2) antifungicidal agents, (3) protective, or (4) wntiinflammatory action. Anv of the antibiotic preparations are effective Lf it is remembered that some are more sensitizing than others. Neomycin, in the form of an ointment or used as a spray (if the ointment is not well tolerated), is a useful agent. A wide range of antifungicidal agents is available, most of which incorporate the fatty acids. Occasionally one must return to the oIder antifungicidal agents such as modiliecl Whitheld’s ointment or modified Castellani’s paint. hlany of these antifungicidal agents are mildly bacteriostatic as well. Not infrequently, a simple protective or emollient ointment is all that is needed to supplement wet dressings. Petrolatum or a hydrated petrolatum will protect the skin, prevent excessive evaporation of moisture, keep the cutaneous surface soft and pliable, and prevent cracking and fissuring. Corticosteroids. Probably the greatest advance in the management of some of these patients, especially those with the dry, lichenified form of essential pruritus ani, is the use of hydrocortisone ointment.‘Y Hydrocortisone may be combined with antibiotics and in some instances may be more effective than simply hvdrocortisone alone.“,3’J The newer Auoro* Xlodified from Frazier and BIank.2”

removed I~>-evaporation of the water in addition to the physical properties of the water itself, so that an open wet compress left uncovered is actually an efficient method for cooling the anorectal area. Thor-e is no evidence that adding boric crystals, potassium permanganate, sodium chloride or Burow’s solution to the water either aids or accclcrates the rate of healing of the lesions. There is no evidence that these substances in themselves are specifically antipruritic. An oozing lesion is said to “dry” faster with the addition of potassium permanganate, I to 8,000 in water. Notwithstanding these scientific facts, the art of medicine often requires of the waters. A wet compress the “coloring” may traumatize the perianal area if it is applied too frequently and for too long a period without allowing the cornified epithelium to dry out bettveen dressings. Maceration is the absorption of water bv the cornified epithelium, resulting in hvdra‘tion and swelling. The amount of water which cornified epithelium will hold is a function of its hydrogen ion concentration. Since water has no buffer capacity, it is not likely to alter the hydrogen ion concentration of the cutaneous surface. It is true that the addition of most salts alters the maceration of the cornihed epithelium very little. Boric acid and potassium permanganate are poor germicides but both may function as bacteriostatic agents. They are, however, applied for such brief periods of time that they cannot be relied upon entirely for bactericidal or bacteriostatic properties. At the Massachusetts General Hospital the dermatologic service has used plain water for wet dressings, soaks and baths for over four years and the results have been equal to those obtained previously wfien various substances were added to the water. L.ori0n.s. In regard to lotions, the cooling effect from simple calamine lotion is very shortlived. The amount of evaporation from the residual surface powder that remains is not significant. Lotions are not bactericidal and it is doubtful that they promote epithelization. Most of the contents of a lotion are chemically inert. If lotions are to be used, the best carrier is alcohol which will cool the skin even better than water. In addition, cooling can be obtained in another way. Some drugs apparently function on the sensory nerve endings to produce a sensation of cooling. Menthol and related substances can be added to Iotions. 811

Fromer cortisone preparations aIs are effective in much smaher dosage. The action of the corticosteroids in the rehef of pruritus ani is not known, but is probabIy on the basis of its anti-inflammatory action. The free aIcoho1 hydrocortisone preparations are more effective than the acetate. If a patient has had a ten-year history of pruritus ani and is relieved in two weeks by local and general measures, it is wise to continue the use of hydrocortisone IocaIIy for six to eight weeks. GraduaI discontinuation is advisabIe to prevent the “rebound” or recurrences seen on sudden withdrawa of the preparation. If the patient is not reIieved appreciably in forty-eight hours with topica steroid therapy, it is usuaIIy necessary to change to another brand or form of the steroid. It is not unusua1, however, to find that patients become resistant to the continued appIications of the corticosteroids IocaIIy, and recourse to the oIder proven therapeutic aids is then in order. This is especiaIIy true in the use of superficial x-ray therapy. This modality, which in the past often was the treatment of choice, is now reserved for patients who do not respond to topica measures. In connection with the hydrocortisone type of therapy, TureII emphasized that “the continua1 topica appIication of any medicament to the anogenita1 area, or erogenous zone, carries the often unrecognized risk of perpetuating or even increasing the severity of the pruritus.“31 He further beIieves that the topica appIication of hydrocortisone preparations is being abused by its promiscuous use, often without a proper examination. This constructive criticism apphes, of course, to a11 IocaI appIications. Systemic Treatment. The systemic treatment of pruritus ani, aside from psychiatric management, had not been emphasized until it was shown by Fromer and Cormia32 that severe anogenital pruritus could be controlled by the systemic administration of ACTH. In a number of patients severe intractabIe disease has been adequateIy controIIed since rgsz when this measure was introduced. An additiona series was reported Iater33 with the same foIIow-up results in the majority of patients. Subsequently, this method of treatment was given wider support by TureII.2 Patients who formerIy required tatooing, cIover Ieaf or undercutting operations, or injections of various preparations incIuding aIcoho1 and long-acting

IocaI anesthetics couId be treated in the hospita1 for four to seven days using ACTH intravenously in diminishing dosages and then maintained at home with ACTH gel for two to three weeks. Once the cycIe of itching was adequately interrupted, healing of the anogenital tissues could go forward without the incessant scratching of the patient. Patients not reIieved by the topical administration of the corticosteroids can stiI1 be treated with this method. The section on proctoIogy at the Lahey CIinic has IargeIy discontinued the surgica1 measures so often used in the past. In our experience the undercutting operations, aIcoho1 injection and other measures have had an exceedingIy temporary effect in a majority of patients and the recurrence rate is so high that these measures, in our opinion, are contraindicated. This high percentage of recurrence in the treatment of pruritus ani can best be explained by the recent work of Lobitz in studies of epiderma1 regeneration or wound healing. 34,35He has shown that experimental scratching or excoriation of the skin, which leads to miId injury without denuding the skin, is followed by a degenerative change of the epiderma1 ceIIs in four hours. Regeneration begins about four hours after this and is compIete in seventy-two hours. Lobitz then found that the epidermis is twice as thick as previously and begins to take on the appearance of the Iichenoid skin seen in essentia1 pruritus ani. If the skin is traumatized by ceIIophane strip or a burr, the time sequence of regeneration goes on as mentioned but two months or Ionger may be required for compIete regeneration or wound heaIing. He has found, further, by the use of seria1 sections and a specia1 stain, that there is obstruction of the sweat pores foIlowed by “dry skin” itching; and if the skin is denuded by scratching, sebaceous elements may be found on the surface of the new epidermis leading to epithelial incIusion cysts and foreign body granulomas. FinaIIy, it is of further interest that if, with a specia1 technic, onIy the dermis is damaged, such as would happen with injections of aIcoho1 or of Iong-acting anesthetics, the epidermis stiI1 responds as if it were primarily damaged, Ieading to thickening of the epidermis and itching Iichenification. The same mechanism expIains the failures seen after IocaI hydrocortisone injections. These not only faiIed to reheve but aIso were folIowed by increased Iichenification

DermatoIogic

Concepts

and pruritus. This again would seem to bear out the thesis that one must avoid trauma in any form including local injections of various substances. Other General A4easures. The occurrence of pruritus ani in patients with a personal or familial background of allergy requires the ufe of elimination diets in at least a fair percentage of these patients. This is not a theoretic consideration, since many patients with this disorder are also investigated in the Department of Gastroenterology. A coexisting diagnosis of irritable bowel or gastrointestinal allergy, or both, with pruritus ani is often made. The institution of dietary changes, antispasmodics and good hygiene ot living suffices to manage the gastrointestinal symptoms as we11 as the anal pruritus. Often these patients are hospitalized and this presents a splendid opportunity to teach them ana hygiene, the careful use of wet dressing and local applications, and the avoidance of toilet paper. Since many patients complain bitterly of nocturnal itching and scratching, chloral hydrate in sufficient dosage to produce sound sleep is the best sedative. According to Lobitz,Z7 sodium salicylate and chloral hydrate often constitute the best combination of sedation and antipruritic form of central contro1 of itching. In some patients the use of the newer “tranquilizers,” chlorpromazine and the Rauwolfia derivatives, is indicated. While the patient is hospitalized, psychosomatic factors may also be evaluated and the aid of a practical psychiatrist enlisted if necessary. Very few patients, in my opinion, will require Iong anaIytic treatment. Most patients have a superficial problem, situational in type, which can often be managed by the non-psychiatrist.‘O During hospitalization all the etiologic factors of this disease can be appreciated, evaluated and then properly treated. COMMENTS

A review of the recent literature on pruritus ani indicates a sincere attempt on the part of investigators and clinicians to approach this subject from a rationa standpoint. Lynch36 discussed cutaneous infection in pruritus, the sensitizing properties of the “caines” and other sensitizing agents such as contraceptive preparations, hygienic pads, deodorants and toiIet waters. He suggested the use of bacitracin ointment or neomycin ointment and has found

of Pruritus

Ani

vioforma ointment effective when secondary infection exists in the eczematized skin. JackmanJ7 discussed the causes of pruritus ani under the following: Systemic causes c5 per cent), which include obesity, jaunclicc, cliabetes and allergy. Local surgical causes (25 per cent), which include hemorrhoids, ectropion of mucosa or mucosal polyps, perineal drainage, sinuses, anal fissures, scarring, stenosis ant1 cryptitis. The non-surgical local causes are condyloma acuminatum, psoriasis, seborrheic dermatitis, dermatitis vencnata and pinworms, fungus, antibiotic therapy. He beIieved pruritus ani was psychogenic in origin in the remainder of the patients; this comprised 70 per cent, of his material. blann”8 stressed the need of a bland diet and removal of foods of highly allergenic sensitizing properties. The importance of maintaining good anal hygiene and the rationale of the use of local preparations in pruritus ani are very well reported by Kallet and DavIin.3!’ The use of corticotropin and cortisone in intractable anogenita1 pruritus was presented by Turells’ He believed that the use of these agents presented a significant advance in the management of these patients. Herfort”” gave cortisone by mouth to patients with pruritus ani, using 300 mg. daily and rapidly reducing the amount to a maintenance dose of 50 mg. daily. Brooke emphasized that the histologic picture of pruritus ani is simiIar to that seen in allergic skin lesions. 4r He achieved excellent results with his method of internal administration of cortisone although he had a small series of cases. Alexander and Ivlanheim4? reported twenty-nine patients treated with a local application of 2.5 per cent hvdrocortisonc acetate ointment. Twenty-six of: twenty-nine obtained relief. The entire subject of the reIationship of anogenital pruritus as a common dermal reaction to antibiotics is discussed by Rees.43 KIigman”l reviewed the entire subject from the standpoint of a dermatoIogist and mycologist. This author, as we11 as Moored5 and Woods, hlanning and Patterson,*‘j also noted the effect of the production of anogenital pruritus and its connection with a secondary monilial involvement in the anogenita1 area. The addition of antifungicidal agents to some of the oral and injectable preparations of the various antibiotics is proof of the concern over this probIem by clinicians and drug manufacturers alike. Warin discussed antihistamine therapy with

Fromer dermatitis, To use one’s favorite topical appIication at the moment bIindIy, without regard to fundamentaIs, is tantamount to adding insuIt to injury.

special reference to skin disorders, and concIuded that this cIass of preparations is only of value in urticaria and has no vaIue in other dermatoIogic disorders.47 Furthermore, in an editoria1 discussion in the British Medical Journal mention is made of the action of the American Council on Pharmacy and Chemistry as “acting upon the opinion of experienced dermatologists-has recently agreed to discontinue the acceptance of dermatoIogica1 preparations of al1 antihistamine drugs and to omit from ‘New and NonoffIcial Remedies’ all currently accepted products in that category.“b* MacAIpine4g studied sixty-four patients with pruritus ani from the standpoint of psychosomatic determinants. He suggested that this symptom in some patients represents a psychopathologic state pointing to a hypochondriacal syndrome which is capable of reduction by psychotherapy. Berezin50 discussed a case report of anogenital pruritus and suggested that the psychodynamic structure is based on the hysterical symptomatoIogy. CaInan and O’NeiII’s workS1 is a sensible psychosomatic approach to this problem which points out that depression, fatigue, irritability, indigestion and a poor tota response to stress are noted in some patients with pruritus ani. These symptoms, which are often overIooked by the busy practitioner, may explain the poor response to treatment in dealing with a patient who is frustrated, resentful and has inborn smoldering anger against some situationa conff ict. Finally, in recent experimental production of itching by local use of histamine, Cormia has shown that the itch threshoId, while variable from patient to patient, was usually constant in a given individua1 when determined under uniform circumstances; the itch threshold was greatly lowered at night and was Iowered in invoIved more than in uninvolved skin, regardIess of demonstrable Iesions. In addition, the itch threshold was Iowered after psychic trauma. The physician who undertakes to manage pruritus ani is treating eczema or dermatitis. Since th.is condition foIIows the Iaws of dermatitis eIsewhere on the body, it foIIows that the general practitioner, proctologist, gynecologist or dermatoIogist who understands the pathoIogic physioIogy of eczema may have Iess dificuIty in the management of pruritus ani. It is far better to classify the disorder, search for the etiology and consider the stage of the

SUMMARY

AND

CONCLUSIONS

) I. A physioIogic approach to the probIem of pruritus ani has been presented. 2. Various factors combine to maintain dermatitis with its attendant pruritus. These factors incIude aIIergic sensitization of the skin by preparations with a high “sensitization index,” change in the pH of the eczematous skin, sweat retention phenomena, bacteria1 and mycotic invasion, and psychosomatic inff uences. 3. Pruritus ani associated with various surgica1, medica or dermatologic probIems is best managed by treatment of the primary condition. This Ieaves a significant group of patients with idiopathic or essentia1 pruritus ani for whom treatment suggestions have been outIined. This group qsponds best to the inteIIigent use of IocaI dermatoIogic measures in addition to general systemic treatment which invoIves the consideration of emotional and aIIergic factors as weI1. REFERENCES

1. SWINTON, N. W. Pruritus ani. New England J. Med., 236: 169-172, 1947. z. TURELL, R. Corticotropin and cortisone in intractabIe anogenita1 pruritus. J. A. M. A., 152: 806-808, ‘953. 3. BECKER, G. L. Recent advances in the IocaI treatment of periana1 skin lesion. Am. J. Surg., 88: 289-292, 1954. 4. LEVER, W. F. HistopathoIogy of the Skin, p. 56. Philadelphia, 1949. J. B. Lippincott Co. 5. ROTHMAN,‘S. @hy&Iogy of itching. Pbysiol. Rev., 21: 357-381, 1941. 6. LOB~TZ, W. C., JR. Some physioIogic aspects of dermatologic problems. New England J. Med., 251: _~_ 545-550, __ 1954. 7. HA&Y, J. D., P&ELUNAS,

C. B. and MEIXNER, M. D. Measurement of Dain threshold and superficial hyperalgesia in &seases of the skin. J. Invest. Dermat., 12: 307-316, 1949. 8. HARDY, J. D., POTELUN&, 6. B. &I MEIXNER, M. D. Pain threshold measurements of human skin folIowing appIication of topica analgesics. J. Invest. De&at.; 16: 369-377, ;gSr. o. , SHELLEY. W. B. and MELTON. F. M. ReIative effect of IocaI anesthetics on experimenta histamine pruritus in man. J. Invest. Dermat., 13: 299-300,

1910. 10. SCHINDLER, J. A. The treatment of emotionally induced iIIness in genera1 medical practice by an audiovisua1 technic. Ann. Int. Med., 42: 909-920, 1955.

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Concepts

ISBI.RY, D. Il. Ph )sw 1.. Iogic principles in manttgement of dermatitis. New En&nd J. Med., 244: 423~429, 1951. 12. STOKES, J. JJ. Chnnging causaI concepts ,znd invcstigativc methods. .I. Inoest. Dermat., 3: 257-,271, I q*o. 13. PERK>, D. J. I.oc:~l use of bcnadryl ointment. J. Invest. Dermut., 9: 95-97, 1947. I4. B~l.o~rnw, D. G. Controlled cIinicaI evaIuation (TI’ relief of pruritus by thephorin ointment. Arch. Dermut. (‘” $$I., 63: 200~261, 195’. 15. &IELTON, F. hl. and SHELLEY, W. B. Effect of topical antipruritic therapy on experimentally induced pruritus in man. J. Invest. Dermat., I 5:

II.

PII

325-332, 195”. 16. BI.ASK, 1. H. hleasurement of pH of the skin surface. I. Technique. J. Incest. Dermat., 2: 67-74, ‘939.

I 7. AKDEKSON, D. S. The acid-base balance of the skin. &it. J. Dermat., 63: 283-296, 1951. I8. SWMID, h'I.Vergleichende Untersuchungen fiber die Slure-Bnscn-Verhaltnisse auf der Haut. Dermc&o~icu, 104: 367-391, 1952. 19. PI;REIKO hircuew., hl. El pH y Is flora de Ios pcquefi:,s pliegues. Actas dermo-siJ., 41: 607-632, 1950. Cittd in: Evcerpta med. (Sec. XIII), 5: 6, 1951. 20. PIL.I.SBIIRY, D. hl. hlanagement of bacterial infections of skin. J. A. M. A., 132: 692-698, 1946. 21. I.IVIUCOOD, C. S. and PILLSBLRY, D. M. Specific sensitivity to foods as factor in various types of rczematous dermatitis. Arch. Dermat. e* Sypb., 60: 1090 I I 15, 1949. 22. S~LZBER(;ER, hl. B., ZIMMERMAN, H. hsl. and EMEKS~K, K., JR. Studies on prickly heat. III. TropicaI anidrotic asthenia (thermogenic anidrosis) and its relationship to prickly heat. J. Invest. Dermut., 7: 153-164, 1946. 23. O’BRIEN, J. P. Study of miliaria rubra, tropical anhidrosis and anhidrotic asthenia. &it. J. Dermut., 59: 125-158, 1947. 24. ((1) SHELLEY, W. B. and HORVATH, P. N. Experimental miliaria in man; production of miliaria rubra (prickly heat). J. Inaest. Dermat., 14: 103-204, 195”; (h) SHELLEY, W. B., WEIDMAN, F. D. and PlLLSsURY, D. hl. Experimental miliaria in man; production of sweat retention anidrosis and vesictes by means of iontophoresis. J. In1~e.Q.Dermat. I I: 275-291, 1948. 25. SIJLZBEKC~EK, hI. B., HARKMANN, F., BOROTA, A. and STKACSS, M. B. Studies of sweating. VI. On the urticariogenic properties of human sweat. J. Inres1. Dermat., 21 : 293-303, 1953. 26. CORMI&, F. E. and KWKENDALL, V. Studies on sweat retention in various dermatoses. Arch. Dermut. t’” Syph., 71 : 425-435, 1955. 27. I.onr~z, \I;. C., JR. and JILLSOY, 0. F. Symposium on dermatology; physiologic approach to management of itching. Postgrad. Med., 12: 2-9, '952.

28.

29.

C. N. and BLANK, I. H. A Formulary for ExtcrnaI Therapy of the Skin, p. 71. Springfield, Illinois, 1954. Charles C Thomas. SULZBERGER, RI. B., WITTEN, V. H. and SMITH, FRAZIER,

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C. C. I lydrocortisonc: iccjmpound I; 1 acc,t;ltc ointment and dcrmatologicnl thcrap! J. 4. .M. A., I 51: 468-472, 1953. 3”. KILE, R. I_. The use of h~droc~,1-tiatr~~~-~~~o~~~~-cin ointment. O/Ii0 State M. J., 49: 1007 loc)X, 1953. 3 I. TUKELL, R. Hydrocortisone therapy in t hc control of anogrnitnl pruritus. J. A. .M. .4., I 58: 113 I-;, 1955. 32. FKOMER, J. L. and COKMIA, F. Adrcnocorticotrophic hormone in severe anopcnital pruritus. J. Invest. Dermat., 18: 1-2, 1952. 33. FROMER, J. L. and SMITH, A. T. The use of ACTI I in ten patients with severe anogcnital pruritus. Luhev Clin. Bull., 7: 232-238, 1C)jZ. 34. LOBITZ, W. C., JK., 1 IOLYOKE, J. B. and \~ONTA(;NA, W. Responses of the human eccrine sweat duct to controlled injury. J. Inz:es~. Dermut., 23: 32()3447 1954. 35. LOBITZ, \I;. C., JR. and HOLYOKE, J. B. The histochemical response of the human epidermis to controlIed injury; glycogen. J. Inzes~. Dermat., 22: 189.-198,1954. views of anorcctal 36. LUUCH, F. W. Dermatologic pruritus. N&u.& M. J., 39: 210 ~2r 2, 1954. of anal pruritus. 37. JACKMAN, R. J. ~Innngemcnt GP, 9: 61-66, 1954. 38. hIAyN, L. S. The clinical management of pruritus ani. J. Internat. Co/l. Surgeons, ~9: 505 -507, 1953. 39. KALLET, II. 1. and DAVLIN, L. P. Ust of an antiseptic synthetic detergent for local hygiene in pruritus nni. J. Michigan 34. SW., ;I : 1447 ~144.8, 15)$2. in the treatment of 40. IIERFORT, R. A. Cortisone pruritus ani. New York Stale J. Med., 53: 2871 2872, 1953.

41. BROOKE, B. R. Perineal pruritus an allergic manifestation? Northwest Med., 38: 462--464, 1939. 42. ALEXANDER, R. kl. and h,lANHEIM, S. D. The efl’ect of hydrocortisonc acetate ointment on pruritus ani. J. Inuest. Dermat., 21: 223-225, 1953. 43. REES, R. B. Anogenital moniliasis. Ctr(ijornicz 12led., 80: 95-97. ‘954. 44. KLIGIIAN, A. hl. Are fungus infections increasing as result of antibiotic therapy? J. A. M. A., 140: 979-983, 1952. 45. hloORE, hl. In viva and in vitro effect of aureomycin hydrochloride on syringospora (monilia, candida) albicans. J. Lab. co* Clin. .Cled., 37: 703-712, 1951. 46. WOODS, J. U’., ~IA~MKG, 1. f-1., JR. and PAT.TEKSON, C. N. hlonilial infections complicating therapeutic use of antibiotics. J. A. EM. ,4., 145: 207211, 19jr. therapy: with special 47. WARI?I, R. P. Antihistamine reference to skin disorders. Rrit. ,%,Z.J., I : 10661069, 1954. Antihistamine druas in dermatologv. 48. Editorial: Brit. M. J., I: 1084-1085, 1954. study. 49. MACALPINE, I. Pruritus ani; a psychiatric Psyc6osom. Med., IS: 499-508, 1953. 50. BEREXN, M. A. Dynamic factors in pruritus ani: case report. Pswhoanalyt. Rev., 41: 16w 172, 1954. 51. CALNAN, C. D. and O’NEILL, D. Itching in tension states. Rril. J. Dermat., 64: 2~4~ 280, 1052. Ii

.,.,