perianal dermatology puritis ani a corman review l.
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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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Presentation Transcript
what to look forward to
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
classification of skin conditions
Classification of Skin Conditions
  • Inflammatory
  • Infectious
  • Neoplastic
  • 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


  • 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


  • Gonorrhea
  • Syphilis
  • Chancroid
  • Granuloma inguinale
  • Lymphogranuloma venereum (Chlamydia infection)
  • Molluscum contagiosum
  • Herpes genitalis
  • Condylomata acuminate
  • Acanthosis nigricans
  • Leukoplakia
  • Mycosis fungoides
  • Leukemia cutis
  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Malignant melanoma
  • Bowen’s disease
  • Extramammary Paget’s disease
pruritus ani
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
pruritus ani differential
Pruritus Ani Differential
  • Hemorrhoids
  • Anal fissure
  • Scarring from prior anal surgery
  • Constipation/diarrhea
  • Contact dermatitis
  • Mycoses
  • Seborrhea
  • Diabetes
  • Pinworm
  • Psoriasis
  • Neurodermatitis
why me why now
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
  • Anoscopy and proctosigmoidoscopy
  • Magnifying lens
  • Woods lamp
  • Skin scrapings
  • Stool assessment?
what you might see
What you might see
  • Marked edema with papillomatosis and nodularing resulting from chronic abrasion
  • Injections of local anesthetics, phenol, and alcohol
  • Methylene blue
  • Diet modification
  • Sterilization?
  • Antibiotics?
  • 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
  • Moisturizers and agents with salicylic acid
  • Topical corticosteroids
  • Coal tar
  • Anthralin
  • Retinoid
  • Vitamin D3 derivatives
  • Ultraviolet B light
  • PUVA treatment
  • Methotrexate and Cyclosporine
lichen planus
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
what you might see17
What you might see
  • Moderate hyperkeratosis, thickening of the stratum granulosum, saw tooth configuration of rete ridges, and lymphocytic infiltration
irritant and contact dermatitis
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
  • 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
what you might see20
What you might see
  • Fibrosis of the dermis with sclerosis, atrophy of the epidermis, and absence of skin appendages
pilonidal sinus
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
why me why now22
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
  • 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
what you might see24
What you might see
  • Multiple openings overlying the sacrum and buttocks
what you might see25
What you might see
  • Indolent, granulating, nonhealing wound of a recurrent (persistent) pilonidal sinus
  • 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
  • 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
std s
  • Gonorrhea
  • Chancroid
  • Chlamydia
  • Herpes Simplex
  • Syphilis:
    • Chancre
    • Condylomata lata
what you might see29
What you might see
  • Large perianal mucoid warty mass composed of smooth-surfaced lobules
  • 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
premalignant lesions
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
skin cancer
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
what you might see33
What you might see
  • Ulcerating tumor has a pearly border
skin cancer34
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
what you might see35
What you might see
  • Ulcerating friable tumor is noted
bowen s disease
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
what you might see37
What you might see
  • An indurated erythemato-squamous patch involving the perianal area
extramammary paget s disease
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
what you might see39
What you might see
  • Irregular but well-marginated erythematous erosive patch with slightly indurated edges
extramammary paget s disease40
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