Series: "Disorders that upset us in gastroenterology"
We chose this title to define a particular set of conditions that are difficult to manage. According to the Dictionary of the Royal Academy, a disorder is defined as a “mild alteration in health” and the verb to upset means “to disturb or remove tranquility or peace.” Doctors are often disturbed by these conditions that, although not serious, greatly upset the patient and represent a frequent reason for consultation. In many cases we lack an effective treatment and the literature is insufficient to help us. The purpose of this guide is to know how far we have come in the study and treatment of these disorders, what experts think and what evidence-based medicine contributes.
Series index
- oral thrush
- burning mouth
- anal itching
- Prolonged hiccups
- Functional anorectal pain
- Belching
- balloon
- Halitosis
In each of them we will make an introduction where we will summarize the basics of current medical knowledge and the treatments usually recommended. Below, we will refer in more depth to the recommended literature and what informs evidence-based medicine when it is available.
Anal pruritus: the clinical problem
Anal pruritus is defined as chronic and intense itching that compromises the perianal skin. It affects 1-5% of the population and varies from mild to severe. When it is severe and persistent, reaching the point that the patient must move away so as not to have to scratch in public, it significantly affects quality of life and can lead to a depressive syndrome.
It is classified as idiopathic when no concomitant lesion is found. However, since some simultaneous pathology is found in 75% of cases, a detailed history and exhaustive examination are required before including it in this category.
A large number of possible causes have been reported but the most common are anorectal, especially hemorrhoids and fissures. Treatment depends on the doctor’s interest in this unattractive pathology of which patients often feel embarrassed.
Epidemiology
It predominates between the fourth and sixth decade of life and is 4 times more common in males.
Etiopathogenesis
In most cases, a cause responsible for the problem is not identified, so it could be said that its origin is idiopathic in 50-90% of cases. A vicious circle is almost always established between itching and scratching, generating lesions that exacerbate the itching.
Fecal contamination of the perianal skin exists as an important cause. This is not only of hygienic origin and is not inevitable either. Fecal contamination can be obvious or hidden; Hidden soiling may be insufficient for the patient to notice but sufficient to cause itching and scratching, causing the vicious circle described.
There are studies that report that patients who suffer from anal itching usually have shapeless stools, and constipation is rare.
Although it occurs in a minority of cases, bacterial or fungal infection or even oxyuriasis must also be taken into account. Fungal infection is responsible for 15% of anal itching. Dermatophytosis or ringworm should also be considered.
Candida, although it is a known commensal, becomes pathogenic in diabetics or after treatment with antibiotics or corticosteroids. Allergic contact dermatitis can be caused by some soaps, wet wipes, and toilet paper with dye.
Some dermatological conditions such as psoriasis can occur in a localized perianal form. The same can be said for lichen and Bowen’s and Paget’s diseases.
Treatment
Dermatological conditions must be treated by the corresponding specialist. The patient should be informed about the chronic nature of the disorder, not only to reduce expectations of rapid cure but also to improve acceptance of the advice given.
Management consists of three aspects that work in parallel
- Avoid irritants and scratching
Elimination measures : Potential irritants such as scratching, creams, soaps, bubble baths, toilet paper, wet wipes, and certain foods and drinks (Table 1) should be avoided
More common
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Others
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Underwear does not have to be tight and should be made of cotton , avoiding synthetic fiber. No perfumed detergents will be used to wash it.
2. General control measures:
The area should be washed with a bidet or shower, without excessive power in the water and avoiding the use of soap, ensuring that after washing, the perineal area is very dry but avoiding rubbing, resorting if necessary to a hair dryer on low temperature.
Although parasitic infections are more common in children, it is worth checking for the presence of pinworms with a Graham test .
The fingernails should be cut closely since the itching worsens at night with the heat of the bed and the patient may scratch while sleeping, maintaining the scratching-itching circle. Some patients have good results using a small cotton ball to keep the area dry.
3. Active treatment:
Local pathology must be investigated and treated. All dermatophytoses (ringworms) should be treated with topical applications of imidazole or terbinafine .
ß hemolytic streptococcus, E aureus and Corynobacterium minutissimum must be eliminated with topical antibiotics such as fusidylic acid .
If the patient does not have constipation, fecal leakage can be reduced by adding fiber or psyllium to the diet, together with loperamide.
The response to an oral antihistamine may also be tested . Mild to moderate symptoms may be treated with a low-concentration topical steroid cream such as 1% hydrocortisone applied morning and evening after washing. In refractory cases, capsaicin and methylene blue tattooing have been used.
Recommended readings
Siddiqi S, Vijay V, Ward M, Mahendran R and Warren S. Pruritus ani. Ann R Coll Surg Engl 2008: 457 -
