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Perianal
Dermatology/Puritis Ani
A Corman Review
Justin Blasberg, MD
9/22/05
What to look forward to?
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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
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Inflammatory
Infectious
Neoplastic
Inflammatory
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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
Infectious
Nonvenereal:
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Pilonidal sinus
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Suppurative hidradenitis
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Anorectal abscess and anal fistula
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Crohn’s disease
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TB
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Actinomycosis
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Fournier’s gangrene
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Ecthyma gangrenosum
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Herpes Zoster
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Vaccinia
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Tinea cruris
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Candidiasis
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“Deep” Mycoses
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Ambebiasis cutis
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Trichomoniasis
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Schistosomiasis cutis
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Bilharziasis
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Oxyuriasis (i.e. pinworm, enterobiasis)
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Creeping eruption (i.e. larva migrans)
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Larva currens
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Cimicosis (i.e. bedbug bites)
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Pediculosis
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Scabies
Infectious
Venereal:
 Gonorrhea
 Syphilis
 Chancroid
 Granuloma inguinale
 Lymphogranuloma venereum (Chlamydia infection)
 Molluscum contagiosum
 Herpes genitalis
 Condylomata acuminate
Neoplastic
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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
Pruritus Ani
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“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
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Chronic itching can lead to atrophic or
hypertrophic skin, with associated nodularity
and scarring
Pruritus Ani Differential
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Hemorrhoids
Anal fissure
Scarring from prior anal surgery
Constipation/diarrhea
Contact dermatitis
Mycoses
Seborrhea
Diabetes
Pinworm
Psoriasis
Neurodermatitis
Why me, why now?
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Increased anal sphincter relaxation in response
to rectal distension
Abnormal rectoanal inhibitory reflexes and a
lower threshold for internal sphincter relaxation
Evaluation
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Anoscopy and proctosigmoidoscopy
Magnifying lens
Woods lamp
Skin scrapings
Stool assessment?
What you might see
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Marked edema with
papillomatosis and
nodularing resulting
from chronic abrasion
Treatment
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Injections of local anesthetics, phenol, and
alcohol
Methylene blue
Diet modification
Sterilization?
Antibiotics?
Psoriasis
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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
Treatment
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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
Lichen Planus
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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 see
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Moderate hyperkeratosis,
thickening of the stratum
granulosum, saw tooth
configuration of rete
ridges, and lymphocytic
infiltration
Irritant and Contact Dermatitis
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Irritant: Nonallergic reaction following
exposure to an irritating substance
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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)
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Dyes, oils, resins, chemicals used on fabrics,
cosmetics, insecticides
Radiodermatitis
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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
What you might see
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Fibrosis of the dermis
with sclerosis, atrophy of
the epidermis, and
absence of skin
appendages
Pilonidal Sinus
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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 now?
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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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Symptoms
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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
What you might see
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Multiple openings
overlying the sacrum and
buttocks
What you might see
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Indolent, granulating,
nonhealing wound of a
recurrent (persistent)
pilonidal sinus
Treatment
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Antibiotics?
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Adjuvant to a surgical procedure
I&D
Definitive therapy:
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Excision, excision with grafting or with an open
wound to close secondarily, cryosurgery, and
injection of sclerosing agents
Tuberculosis
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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
STD’s
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Gonorrhea
Chancroid
Chlamydia
Herpes Simplex
Syphilis:
Chancre
 Condylomata lata
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What you might see
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Large perianal mucoid
warty mass composed of
smooth-surfaced lobules
Neoplastic
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Premalignant Lesions
Acanthosis Nigricans-ominous association with
abdominal cancer
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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
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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
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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
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Ulcerating tumor has a
pearly border
Skin Cancer
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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
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Ulcerating friable tumor
is noted
Bowen’s disease
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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 see
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An indurated
erythemato-squamous
patch involving the
perianal area
Extramammary Paget’s Disease
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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
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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 see
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Irregular but wellmarginated erythematous
erosive patch with
slightly indurated edges
Extramammary Paget’s Disease
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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