Assessment of the anxiety and depression among patients with idiopathic pruritus ani

Introduction

Pruritus ani is an unpleasant sensation that leads to scratching of the skin around the anus. It is a common symptom due to many systemic, dermatological, and proctological conditions. In the absence of evident organic origin of a disease, pruritus may be related to mental disorders as well as personality disorders.

Aim

To assess the influence of pruritus on anxiety and depression in these patients.

Material and methods

The study involved 60 patients complaining of persistent pruritus ani. The study included people in which pruritus for organic reasons was ruled out. Tests were carried out to assess the level of depression and anxiety disorders. In addition, patients were asked to fill in the Questionnaire for the Descriptive Assessment of Pruritus and the 4-Item Itch Questionnaire by prof. Jacek Szepietowski.

Results

The cause of pruritus ani in the study groups has been shown to have a significant influence on the level of depressive symptoms. There was no such relationship for anxiety disorders. In the study group, there was no correlation of depressive-anxiety symptoms with the level of pruritus intensity and the frequency of pruritus.

Conclusions

The presented data reveal the negative effect of pruritus ani on the psychological functioning of patients. Pruritus ani is characterized by moderate intensity of pruritus, but has a significant influence on the aggravation of depressive symptoms. It is important to look for the causes of this symptom, which can help to eliminate its intensity, improve the patients’ mood, and thus improve their quality of life.

Idiopathic Pruritus Ani and Acute Perianal Dermatitis

This article reviews the etiologies, pathophysiology, clinical evaluation, and treatment of idiopathic pruritus ani and perianal dermatitis. It underscores a practical approach to each of these common proctologic conditions.

Recalcitrant anal and genital pruritus treated with dupilumab

Chronic anogenital pruritus can significantly impair affected patients’ quality of life by disrupting their sleep, mood, sexual function, and personal relationships. Although a significant portion of these patients can be managed with hygiene measures, topical therapy, oral anti-pruritics, and allergen avoidance after patch testing, guidelines to treat patients who do not respond to standard therapy have yet to be established. We describe the therapeutic response of a case of anogenital pruritus recalcitrant to multiple topical and systemic therapies. Treatment of this patient with dupilumab, an interleukin-4 receptor alpha blocker, resulted in clinical remission at 1 year from the initiation of the therapy, without significant adverse effects.

Pruritus Ani

Pruritus ani is a common condition with many different potential causes. Because of this, it can be difficult to treat. It is important to identify and eliminate any inciting factors, which are often unintentional consequences of the patient's attempts to alleviate symptoms. If no reversible cause is found, simple measures with diet modification and perianal hygiene are tried before using topical medications or procedures.

Common anorectal disorders

Anorectal disorders result in many visits to healthcare specialists. These disorders include benign conditions such as hemorrhoids to more serious conditions such as malignancy; thus, it is important for the clinician to be familiar with these disorders as well as know how to conduct an appropriate history and physical examination. This article reviews the most common anorectal disorders, including hemorrhoids, anal fissures, fecal incontinence, proctalgia fugax, excessive perineal descent, and pruritus ani, and provides guidelines on comprehensive evaluation and management.

Hidradenitis suppurativa and pruritus ani

Hidradenitis suppurativa (HS) is a chronic debilitating disorder that can affect any areas bearing apocrine glands. Perineal HS is associated with high morbidity compared with other anatomic regions. Early-stage disease may mimic various other forms of cutaneous disorders, but as HS progresses pathognomonic skin changes occur. Clinical stage can guide the therapeutic approach, but the lowest recurrence rate is obtained by removing all involved skin and subcutaneous fat. Pruritus ani is a complex disease with a multitude of etiologies. Its management can be frustrating and disappointing for the patient and doctor alike. The key is to start with simple treatment options focusing on perianal hygiene and avoidance of the most common offending foods and beverages. If these measures fail, topical medications should be attempted before graduating to perianal injections of methylene blue as a last resort.

Relationship between anal symptoms and anal findings

BACKGROUND

The frequencies and types of anal symptoms were compared with the frequencies and types of benign anal diseases (BAD).

METHODS

Patients transferred from GPs, physicians or gynaecologists for anal and/or abdominal complaints/signs were enrolled and asked to complete a questionnaire about their symptoms. Proctologic assessment was performed in the knee-chest position. Definitions of BAD were tested in a two year pilot study. Findings were entered into a PC immediately after the assessment of each individual.

RESULTS

Eight hundred seven individuals, 539 (66.8%) with and 268 without BAD were analysed. Almost one third (31.2%) of patients with BAD had more than one BAD. Concomitant anal findings such as skin tags were more frequently seen in patients with than without BAD (<0.01). After haemorrhoids (401 patients), pruritus ani (317 patients) was the second most frequently found BAD. The distribution of stages in 317 pruritus ani patients was: mild (91), moderate (178), severe (29), and chronic (19). Anal symptoms in patients with BAD included: bleeding (58.6%), itch (53.7%), pain (33.7%), burning (32.9%), and soreness (26.6%). Anal lesions could be predicted according to patients' answers in the questionnaire: haemorrhoids by anal bleeding (p=0.032), weeping (p=0.017), and non-existence of anal pain (p=0.005); anal fissures by anal pain (p=0.001) and anal bleeding (p=0.006); pruritus ani by anal pain (p=0.001), itching (p=0.001), and soreness (p=0.006).

CONCLUSIONS

The knee-chest position may allow for the accumulation of more detailed information about BAD than the left lateral Sims' position, thus enabling physicians to make more reliable anal diagnoses and provide better differentiated therapies.

Patients' views of medical positioning for proctologic examination

Background:

It is unknown which proctological position is most embarrassing to patients.

Methods:

Individuals consecutively referred to our outpatient clinic in order to determine the causes of anal and/or abdominal complaints were randomized to complete an unvalidated six-item questionnaire which asked for their preferred proctologic positioning either before or after a proctological examination in knee–chest position followed by inspection of the anal verge, digital examination of the anal canal, and anoscopy. A third group of patients referred for gastroscopy was asked to complete the questionnaire before being gastroscoped.

Results:

One hundred seventy-eight individuals of both genders aged 16–80 years who consecutively entered our outpatient clinic were enrolled. One third in each group had never experienced any of the offered medical positionings. Most patients favored the Sims’ position if they had the choice. Randomized patients favored the knee–chest position more after experiencing it compared to those without experience (P < 0.03). Patients favored the positions they had recently experienced irrespective of the other positions offered in the questionnaire (P < 0.05). Individual answers to the question ‘which position do you find most embarrassing?’ did not depend on sex or age at first examination or when their last examination was performed. The majority of patients (55.2%–71.4%) held that no type of proctological positioning was most embarrassing to them.

Conclusions:

The medical profession is authorized to use the proctological positioning that allows the most reliable anal diagnoses.

Topical capsaicin--a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study

PURPOSE

Pruritus ani is a common and embarrassing proctological condition which can be very difficult to treat. We report the results of a double blind placebo controlled study of treatment with capsaicin.

METHODS

Firstly, a pilot open study was carried out on five patients to establish which of two doses was the most acceptable by comparing effectiveness and side effects. Secondly, a double blind, placebo controlled, crossover study of topical capsaicin was performed. This study involved two four week treatment phases separated by a one week washout phase. Forty four patients were randomised to receive locally either active capsaicin (0.006%) or placebo (menthol 1%) ointment over a four week period (22 patients per group). After four weeks of treatment and a one week washout period, the placebo group began to receive capsaicin while the treated group received placebo (menthol 1%) for another four weeks. At the end of the controlled study, responders from both groups continued with capsaicin treatment in an open labelled manner.

RESULTS

Thirty one of 44 patients experienced relief during capsaicin treatment periods and did not respond to menthol; all patients not responding to capsaicin also failed on menthol (p<0.0001). In 13 patients, treatment with capsaicin was unsuccessful: eight patients did not respond to capsaicin treatment, one responded equally to capsaicin and placebo, and four others dropped out because of side effects. During the follow up period (mean 10.9 (SD 5.8) months), 29 "responders" needed a mean application of capsaicin every day (1.6 (SD 1.2); range 0.5-7 days) to remain symptom free (or nearly symptom free).

CONCLUSION

Capsaicin is a new, safe, and highly effective treatment for severe intractable idiopathic pruritus ani.