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Perianal Dermatology/Puritis Ani A Corman Review. Justin Blasberg, MD 9/22/05. What to look forward to?. Description of skin conditions affecting the perianal area Review of the differential diagnosis Examples of common and uncommon findings Treatment of the relevant diseases.

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Perianal dermatology puritis ani a corman review l.jpg

Perianal Dermatology/Puritis AniA Corman Review

Justin Blasberg, MD


What to look forward to l.jpg

What to look forward to?

  • Description of skin conditions affecting the perianal area

  • Review of the differential diagnosis

  • Examples of common and uncommon findings

  • Treatment of the relevant diseases

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Classification of Skin Conditions

  • Inflammatory

  • Infectious

  • Neoplastic

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  • Pruritus ani

  • Psoriasis

  • Lichen planus

  • Lichen sclerosus et atrophicus

  • Atrophoderma

  • Contact (allergic) dermatitis

  • Seborrheic dermatitis

  • Radiodermatitis

  • Behcet’s syndrome

  • Lupus erythematosus

  • Dermatomyositis

  • Scleroderma

  • Erythema multiforme

  • Familial benign chronic pemphigus (i.e. Hailey-Hailey)

  • Pemphigus vulgaris

  • Cicatricial pemphigoid

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  • Pilonidal sinus

  • Suppurative hidradenitis

  • Anorectal abscess and anal fistula

  • Crohn’s disease

  • TB

  • Actinomycosis

  • Fournier’s gangrene

  • Ecthyma gangrenosum

  • Herpes Zoster

  • Vaccinia

  • Tinea cruris

  • Candidiasis

  • “Deep” Mycoses

  • Ambebiasis cutis

  • Trichomoniasis

  • Schistosomiasis cutis

  • Bilharziasis

  • Oxyuriasis (i.e. pinworm, enterobiasis)

  • Creeping eruption (i.e. larva migrans)

  • Larva currens

  • Cimicosis (i.e. bedbug bites)

  • Pediculosis

  • Scabies

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  • Gonorrhea

  • Syphilis

  • Chancroid

  • Granuloma inguinale

  • Lymphogranuloma venereum (Chlamydia infection)

  • Molluscum contagiosum

  • Herpes genitalis

  • Condylomata acuminate

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  • Acanthosis nigricans

  • Leukoplakia

  • Mycosis fungoides

  • Leukemia cutis

  • Basal cell carcinoma

  • Squamous cell carcinoma

  • Malignant melanoma

  • Bowen’s disease

  • Extramammary Paget’s disease

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Pruritus Ani

  • “itching in the anal area”

  • Symptoms:

    • Itching of anal and genital areas

    • Worsening at night

    • May awaken the patient from sleep

    • Scratching with exacerbation of complaint

  • Chronic itching can lead to atrophic or hypertrophic skin, with associated nodularity and scarring

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Pruritus Ani Differential

  • Hemorrhoids

  • Anal fissure

  • Scarring from prior anal surgery

  • Constipation/diarrhea

  • Contact dermatitis

  • Mycoses

  • Seborrhea

  • Diabetes

  • Pinworm

  • Psoriasis

  • Neurodermatitis

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Why me, why now?

  • Increased anal sphincter relaxation in response to rectal distension

  • Abnormal rectoanal inhibitory reflexes and a lower threshold for internal sphincter relaxation

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  • Anoscopy and proctosigmoidoscopy

  • Magnifying lens

  • Woods lamp

  • Skin scrapings

  • Stool assessment?

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What you might see

  • Marked edema with papillomatosis and nodularing resulting from chronic abrasion

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  • Injections of local anesthetics, phenol, and alcohol

  • Methylene blue

  • Diet modification

  • Sterilization?

  • Antibiotics?

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  • Chronic inflammatory disease of the skin

  • 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

  • Butterfly distribution over the coccyx and sacrum

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  • Moisturizers and agents with salicylic acid

  • Topical corticosteroids

  • Coal tar

  • Anthralin

  • Retinoid

  • Vitamin D3 derivatives

  • Ultraviolet B light

  • PUVA treatment

  • Methotrexate and Cyclosporine

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Lichen Planus

  • Eruption of small, flat-topped papules with a distinct violaceous color and polypoid configuration

  • 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

  • Diagnosis made with skin biopsy

  • Treatment with corticosteroids and occlusive dressings

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What you might see

  • Moderate hyperkeratosis, thickening of the stratum granulosum, saw tooth configuration of rete ridges, and lymphocytic infiltration

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Irritant and Contact Dermatitis

  • Irritant: Nonallergic reaction following exposure to an irritating substance

    • 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)

    • Dyes, oils, resins, chemicals used on fabrics, cosmetics, insecticides

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  • Secondary to radiotherapy of the rectum, anus, and prostate

  • Cell mitosis is arrested; skin change results from the dosage of radiotherapy

  • Erythema, edema, ulceration, and symptoms of burning, itching, or severe pain

  • Treatment with oral Vitamin A 8000IU BID

  • Hyperbaric O2 has also been found to be helpful

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What you might see

  • Fibrosis of the dermis with sclerosis, atrophy of the epidermis, and absence of skin appendages

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Pilonidal Sinus

  • Common infective process occurring in the natal cleft and sacrococcygeal region

  • Affects young adults and teenagers

  • 3:1 male predominance

  • Epithelium lined sinus is usually found to contain hair

  • 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

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Why me, why now?

  • 2 Theories of formation:

    • 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

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  • Pain, swelling, purulent drainage at and around the site of the pilonidal opening

  • Typical appearance of an abscess may be evident

  • Fever and leukocytosis may be present

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What you might see

  • Multiple openings overlying the sacrum and buttocks

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What you might see

  • Indolent, granulating, nonhealing wound of a recurrent (persistent) pilonidal sinus

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  • Antibiotics?

    • Adjuvant to a surgical procedure

  • I&D

  • Definitive therapy:

    • Excision, excision with grafting or with an open wound to close secondarily, cryosurgery, and injection of sclerosing agents

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  • Confused for Crohn’s, actinomycosis, anal fistula, colloid carcinoma, sarcoidosis, other skin conditions

  • Anal fistula is the most frequent presentation

  • 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

  • Treatment: anti-TB drugs with resolve usually in 2 to 3 weeks

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  • Gonorrhea

  • Chancroid

  • Chlamydia

  • Herpes Simplex

  • Syphilis:

    • Chancre

    • Condylomata lata

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What you might see

  • Large perianal mucoid warty mass composed of smooth-surfaced lobules

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  • Premalignant Lesions

  • Acanthosis Nigricans-ominous association with abdominal cancer

    • Affects face, neck, axillae, external genitalia, groin, inner thighs, umbilicus, and anus

    • Grayish velvety thickening or roughening of the skin

    • Epidermal papillomatosis, hyperkeratosis, and hyperpigmentation

    • Treatment is directed to the primary malignant condition

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Premalignant Lesions

  • Leukoplakia

    • Whitish thickening of the mucous membrane epithelium occurring in patches of diverse size and shape

    • Seen in the anal canal

    • Associated with an increased risk of malignancy/epidermoid carcinoma

    • Symptoms of bleeding, discharge, and pruritic symptoms are the most common complaints

    • Hyperkeratosis and squamous metaplasia

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Skin Cancer

  • Basal Cell Carcinoma

    • Most common cutaneous malignancy, extremely rare in the anal area

    • Tumors usually between 1-2 cm

    • Presents with a lump or ulcer

    • Bleeding, pain, pruritis, and discharge may be present

    • Treat with local excision and adequate margins

    • APR resection is performed for extensive or infiltrating tumors

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What you might see

  • Ulcerating tumor has a pearly border

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Skin Cancer

  • Squamous Cell/Epidermoid carcinoma

    • Tumor appears superficial, discrete, and hard

    • Ulcerates with progression

    • Mets to regional lymph nodes can occur

    • Treat with wide local excision

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What you might see

  • Ulcerating friable tumor is noted

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Bowen’s disease

  • Intraepidermal squamous cell carcinoma that spreads intraepidermally

  • Precursor to squamous cell carcinoma of the anus

  • Associated with HPV infection

  • Itching and burning, pain and bleeding

  • Treatment wide local excision with frozen section to ensure adequate margins

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What you might see

  • An indurated erythemato-squamous patch involving the perianal area

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Extramammary Paget’s Disease

  • Large, round, clear-staining cells with large nuclei

  • Symptoms of ulceration, discharge, pruritis, and occasionally bleeding and pain

  • Treatment depends on the presence/absence or underlying 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

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What you might see

  • Irregular but well-marginated erythematous erosive patch with slightly indurated edges

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Extramammary Paget’s Disease

  • 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 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 IV-distant mets-tx with standard palliative cancer management

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