1 / 36

Itchy Butt and the Burn

2/2/11. Itchy Butt and the Burn. Perianal skin. Subject to virtually all the diseases that affect the rest of the skin Requires accurate diagnosis to eliminate diseases with specific cause and treatment Organized approach to diagnosis Frequent biopsy

nerina
Download Presentation

Itchy Butt and the Burn

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. 2/2/11 Itchy Butt and the Burn

  2. Perianal skin • Subject to virtually all the diseases that affect the rest of the skin • Requires accurate diagnosis to eliminate diseases with specific cause and treatment • Organized approach to diagnosis • Frequent biopsy • Must properly examine the anus with appropriate instruments and bright light

  3. PruritusAni • Of Latin derivation meaning itchy anus • Primary • Classic syndrome of idiopathic pruritusani • Secondary • Identifiable cause or specific diagnosis • Macules • Flat spots • Papules • Elevated, circumscribed solid lesions, raised spots • Bulla • Larger vesicles or blisters

  4. PruritusAni • Pustules • Contain pus • Ulcers • Surface lesions with loss of continuity of the skin and result from rupture of vesicular lesions, infection, or trauma • Intertrigo • Inflammation seen between two opposing skin surfaces (mixed infxn assoc with moisture, obesity, and poor hygiene)

  5. Physiologic Considerations • Surface phenomenon mediated by pain fibers • In the epidermis • May have lower threshold for stimulation than pain • Innocuous, nondamaging stimuli may induce itching • Histamine, kallikrein, bradykinin, papin, and trypsin produce itching that don’t respond to histamine antagonists

  6. Scratching • Scratching with subsequent injury may produce an enlarged patch of itchy skin • Produces inadequate feedback to inhibit itching • More scratching occurs with cutaneous injury • Provides more stimulus to scratch • Self-defeating loop • Substituting heat, cold, pain or stinging may provide an inhibitory feedback and stop the urge to scratch

  7. Etiology • Localized Itch Syndromes • Notalgia paresthetica • Itching or pain of upper mid back to scapula • Attributed to spinal nerve damage or entrapment • Family of 8 has been described • Skin biopsies show increases in sensory innervation • Tx by capsiacin cream or EMLA cream • Dermatographism • Skin changes are the sole result of skin trauma

  8. Etiology • Fecal Contamination • Proven by patch test study done • Prompt appearance of symptoms and relief with washing believed to indicate an irritant effect • Seepage of liquid and mucus is important in causing symptoms • Coffee lowers resting pressures and may contribute • Anal inhibitory reflex is more pronounced • Rectal distention makes patients more prone to leak and soil

  9. Etiology • Viral Infection • Condyloma acuminata • Papilloma virus infection • Anal intraepithelial neoplasia (AIN) • Herpes • Usually accompanied by pain • Molluscum contagiosum • HIV with secondary fungal infection • Fungal Infection • Dermatophytes • Trichophyton rubrum • Candida in the presence of steroids

  10. Candidiasis

  11. Etiology • Bacterial Infection • β hemolytic strep • Erythrasma • Corynebacterium • Wood’s light—coral pink • Cure with EES • Staph aureus • highly treatable with topical agents • Psoriasis • Don’t appear as typical because of maceration • Fluocinolone acetonide • Biopsy not reliable

  12. Erythrasma—coral pink

  13. Psoriasis

  14. Etiology • Contact Dermatitis • Exematous inflammation characterized by erythema, scale, and vesicles • Topical anesthetics (procaine) • Topical antibiotics (neomycin) • Topical antiseptics • Topical antihistamines • Nickel • Avoidance of contact • Topical steroids • Avoid soaps, wipes • Use bath oils for cleaning

  15. Etiology • Lichen Sclerosis • Chronic dz of unknown cause • Female/male 10:1 • White, atrophic, and wrinkled • Involvement of labia is characteristic • Biopsy needed to r/o SCC if not responding to treatment • Clobetasol propionate for 6-8 wks • Tacrolimus ointment

  16. Lichen Sclerosis

  17. Etiology—Food Factors • Coffee (2-3 cups) • Tea (4 cups) • Cola • Beer (less than 2 cans) • Chocolate • Tomato (ketchup) • Coffee • Alcohol • Peanuts • Chocolate • Milk products • Cola • Citrus

  18. Etiology • Coexisting Anal Dz • Hemorrhoids • Prolapse may induce soiling • Skin tags may interfere with hygiene • Fissure • Fistula • Psychologic Factors • Anxiety • Stress • Fatigue • Personality • Coping skills • Obsessive compulsive disorder

  19. Etiology • Steriod Induced Itching • Rebound phenomenon after withdrawal of steroids • Steroid addiction • Can lead to permanent deformity and dependence • Should be tapered • Skin Trauma • Diarrhea or frequent stools • Frequent wiping and maceration • Scratching while asleep

  20. Etiology—Neoplasms • Perianal Paget’s • Rare • More than half of patients have itching, often longer than 3 months at presentation • Perianal Bowen’s • Intraepithelial squamous cell carcinoma in situ • Also rare • 60% presented with itching as main complaint

  21. Bowen’s Disease

  22. Etiology—Neoplasms • AIN • Sequel to HPV • Refers to premalignant change in area of dentate line and anal transition zone

  23. Diagnosis • General classifications • Mass—inflammatory or neoplastic • Rash • Fissure—primary or secondary • Morphology • Crusts • Herpes genitalis • Scabies

  24. Diagnosis • Papules • Venereal warts • Scabies • Molluscum contagiosum • Candidiasis • Syphilis • Diffuse erythema • Candidiasis • Trauma • Contact dermatitis • Fixed drug eruption

  25. Diagnosis • Ulcers • Herpes genitalis • Syphilis • Trauma • Chancroid • Fixed drup eruption • Lymphogranuloma venereum • Tularemia • Behcet’s syndrome • Donovanosis (granuloma inguinale) • Candidiasis • Histoplasmosis • Mycobacterioses • Amebiasis • Gonorrhea • Trichomoniasis • Malignancy

  26. Diagnosis • Miscellaneous findings • Linear tracks • Scabies • Reddish flecks • Crab louse excreta • Maculae ceruleae (sky-blue spots) • Crab lice • Nits • Crab lice • Hypertrophic • donovanosis

  27. History and physical • History • Other skin conditions, allergies, other sites of involvement, asthma, urticaria • OTC or nonRx meds • Chemicals, clothes, laundry • Infections, colds, or diarrhea • Antibiotic use • Physical • Multiple sites--Check the groin! • Hyperpigmentation • Lichenification • Ulceration • Adenopathy • Defined margins

  28. Labs • Aspiration • Swab • Bacterial and fungal cultures • Viral cultures • Skin scrapings • Punch biopsy

  29. Treatment • Control seepage and fecal contamination • Fiber for loose stools • Immodium or Lomotil to lessen frequency or firm up stools • Questran can firm loose stools

  30. Treatment • Removal of irritants—soaps, perfumes, dyes in clothes or wiping tissues, alcohol or witch-hazel containing agents, and moisture • Dove is a preferred bathing agent • Dilute white vinegar on a cotton ball is an alternate non-soapy cleaner • Burow’s solution is another nonirritating cleanser and can be used as an antibacterial soak for 5-15 min

  31. Treatment • Hand held showers or bidets for cleaning perianal area • Use of a hair dryer to eliminate moisture • Athlete’s foot powder or barrier cream to lubricate and prevent maceration • Zeasorb—powder form • Avoid cornstarch—medium for yeast • Balneol—mineral oil based prep that’s portable

  32. Treatment • Topical anesthetics, menthol, phenol, camphor can control symptoms • Topical steroids, antifungals,and antibacterials can be used • Pepper creams may eliminate need to scratch by providing a more painful stimulus

  33. Treatment • Loose underwear that allows circulation • Laundry detergents without perfumes • May add chlorine bleach to keep bacterial counts down • Berwick’s dye—genetian violet and brilliant green • Has alcohol content and stings • Dry and follow with benzoin—lasts several days • Not for home application

  34. Treatment • High potency steroids should only be used for a limited period of time • 4-8 weeks • Can then switch to low potency steroid with tapering to cessation • Prolonged use can cause skin atrophy • More notable with creams than ointments • Topical immunomodulators do not cause atrophy and may have antifungal properties • Silver sulfadiazine can promote re-epithelializtion when skin is denuded

  35. Treatment • Anal tattooing • Intradermal and subcutaneous injection of • 10 mL 1 % methylene blue • 5 mL normal saline • 7.5 mL 0.25% bupivicaine with epi • 7.5 mL 0.5% lidocaine • 27 or 30 gauge needle to inject multiple sites to cover perianal involved skin up to the dentate line

More Related