Perianal Dermatology/Puritis

AniA Corman Review

Justin Blasberg, MDJustin Blasberg, MD

9/22/059/22/05

What to look forward to?What to look forward to?

Description of skin conditions Description of skin conditions affecting the perianal areaaffecting the perianal area

Review of the differential diagnosisReview of the differential diagnosis Examples of common and uncommon Examples of common and uncommon

findingsfindings Treatment of the relevant diseasesTreatment of the relevant diseases

Classification of Skin Classification of Skin ConditionsConditions

InflammatoryInflammatory InfectiousInfectious NeoplasticNeoplastic

InflammatoryInflammatory Pruritus aniPruritus ani PsoriasisPsoriasis Lichen planusLichen planus Lichen sclerosus et atrophicusLichen sclerosus et atrophicus AtrophodermaAtrophoderma Contact (allergic) dermatitisContact (allergic) dermatitis Seborrheic dermatitisSeborrheic dermatitis RadiodermatitisRadiodermatitis Behcet’s syndromeBehcet’s syndrome Lupus erythematosusLupus erythematosus DermatomyositisDermatomyositis SclerodermaScleroderma Erythema multiformeErythema multiforme Familial benign chronic pemphigus (i.e. Hailey-Hailey)Familial benign chronic pemphigus (i.e. Hailey-Hailey) Pemphigus vulgarisPemphigus vulgaris Cicatricial pemphigoidCicatricial pemphigoid

InfectiousInfectiousNonvenereal:Nonvenereal: Pilonidal sinusPilonidal sinus Suppurative hidradenitisSuppurative hidradenitis Anorectal abscess and anal fistulaAnorectal abscess and anal fistula Crohn’s diseaseCrohn’s disease TBTB ActinomycosisActinomycosis Fournier’s gangreneFournier’s gangrene Ecthyma gangrenosumEcthyma gangrenosum Herpes ZosterHerpes Zoster VacciniaVaccinia Tinea crurisTinea cruris CandidiasisCandidiasis ““Deep” MycosesDeep” Mycoses Ambebiasis cutisAmbebiasis cutis TrichomoniasisTrichomoniasis Schistosomiasis cutisSchistosomiasis cutis BilharziasisBilharziasis Oxyuriasis (i.e. pinworm, enterobiasis)Oxyuriasis (i.e. pinworm, enterobiasis) Creeping eruption (i.e. larva migrans)Creeping eruption (i.e. larva migrans) Larva currensLarva currens Cimicosis (i.e. bedbug bites)Cimicosis (i.e. bedbug bites) PediculosisPediculosis ScabiesScabies

InfectiousInfectious

Venereal:Venereal: GonorrheaGonorrhea SyphilisSyphilis ChancroidChancroid Granuloma inguinaleGranuloma inguinale Lymphogranuloma venereum (Chlamydia Lymphogranuloma venereum (Chlamydia

infection)infection) Molluscum contagiosumMolluscum contagiosum Herpes genitalisHerpes genitalis Condylomata acuminateCondylomata acuminate

NeoplasticNeoplastic Acanthosis nigricansAcanthosis nigricans LeukoplakiaLeukoplakia Mycosis fungoidesMycosis fungoides Leukemia cutisLeukemia cutis Basal cell carcinomaBasal cell carcinoma Squamous cell carcinomaSquamous cell carcinoma Malignant melanomaMalignant melanoma Bowen’s diseaseBowen’s disease Extramammary Paget’s diseaseExtramammary Paget’s disease

Pruritus AniPruritus Ani

““itching in the anal area”itching in the anal area” Symptoms:Symptoms:

Itching of anal and genital areasItching of anal and genital areas Worsening at nightWorsening at night May awaken the patient from sleepMay awaken the patient from sleep Scratching with exacerbation of Scratching with exacerbation of

complaintcomplaint Chronic itching can lead to atrophic Chronic itching can lead to atrophic

or hypertrophic skin, with associated or hypertrophic skin, with associated nodularity and scarringnodularity and scarring

Pruritus Ani DifferentialPruritus Ani Differential HemorrhoidsHemorrhoids Anal fissureAnal fissure Scarring from prior anal surgeryScarring from prior anal surgery Constipation/diarrheaConstipation/diarrhea Contact dermatitisContact dermatitis MycosesMycoses SeborrheaSeborrhea DiabetesDiabetes PinwormPinworm PsoriasisPsoriasis NeurodermatitisNeurodermatitis

Why me, why now?Why me, why now?

Increased anal sphincter relaxation Increased anal sphincter relaxation in response to rectal distension in response to rectal distension

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

EvaluationEvaluation

Anoscopy and proctosigmoidoscopy Anoscopy and proctosigmoidoscopy Magnifying lens Magnifying lens Woods lampWoods lamp Skin scrapingsSkin scrapings Stool assessment?Stool assessment?

What you might seeWhat you might see

Marked edema Marked edema with papillomatosis with papillomatosis and nodularing and nodularing resulting from resulting from chronic abrasionchronic abrasion

TreatmentTreatment

Injections of local anesthetics, Injections of local anesthetics, phenol, and alcohol phenol, and alcohol

Methylene blue Methylene blue Diet modificationDiet modification Sterilization?Sterilization? Antibiotics?Antibiotics?

PsoriasisPsoriasis

Chronic inflammatory disease of the skinChronic inflammatory disease of the skin Characterized by rounded circumscribed Characterized by rounded circumscribed

erythematous dry scaling patches covered erythematous dry scaling patches covered by grayish white or silvery white scalesby grayish white or silvery white scales

Predilection for scalp, nails, extensor Predilection for scalp, nails, extensor surfaces or limbs, elbows, knees, and surfaces or limbs, elbows, knees, and sacral regionssacral regions

Butterfly distribution over the coccyx and Butterfly distribution over the coccyx and sacrumsacrum

TreatmentTreatment Moisturizers and agents with salicylic acidMoisturizers and agents with salicylic acid Topical corticosteroidsTopical corticosteroids Coal tarCoal tar AnthralinAnthralin RetinoidRetinoid Vitamin D3 derivativesVitamin D3 derivatives Ultraviolet B lightUltraviolet B light PUVA treatmentPUVA treatment Methotrexate and CyclosporineMethotrexate and Cyclosporine

Lichen PlanusLichen Planus Eruption of small, flat-topped papules with a Eruption of small, flat-topped papules with a

distinct violaceous color and polypoid distinct violaceous color and polypoid configurationconfiguration

Found in flexor surfaces, mucous membranes, Found in flexor surfaces, mucous membranes, genitalia, and perianal areagenitalia, and perianal area

Focal thickening of the granular layer, Focal thickening of the granular layer, degeneration of the basement membrane and basal degeneration of the basement membrane and basal cells, and a bandlike lymphocytic infiltrate in the cells, and a bandlike lymphocytic infiltrate in the upper dermisupper dermis

Diagnosis made with skin biopsyDiagnosis made with skin biopsy Treatment with corticosteroids and occlusive Treatment with corticosteroids and occlusive

dressingsdressings

What you might seeWhat you might see

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

Irritant and Contact Irritant and Contact DermatitisDermatitis

Irritant: Nonallergic reaction following Irritant: Nonallergic reaction following exposure to an irritating substanceexposure to an irritating substance Alkalis, acids, metal salts, dusts, gases, Alkalis, acids, metal salts, dusts, gases,

and hydrocarbonsand hydrocarbons Allergic (contact): Allergic sensitivity Allergic (contact): Allergic sensitivity

to a number of responsible agents, also to a number of responsible agents, also known as hypersensitivity of the known as hypersensitivity of the delayed type (cell mediated delayed type (cell mediated hypersensitivity)hypersensitivity) Dyes, oils, resins, chemicals used on Dyes, oils, resins, chemicals used on

fabrics, cosmetics, insecticidesfabrics, cosmetics, insecticides

RadiodermatitisRadiodermatitis Secondary to radiotherapy of the rectum, Secondary to radiotherapy of the rectum,

anus, and prostateanus, and prostate Cell mitosis is arrested; skin change Cell mitosis is arrested; skin change

results from the dosage of radiotherapyresults from the dosage of radiotherapy Erythema, edema, ulceration, and Erythema, edema, ulceration, and

symptoms of burning, itching, or severe symptoms of burning, itching, or severe painpain

Treatment with oral Vitamin A 8000IU Treatment with oral Vitamin A 8000IU BIDBID

Hyperbaric O2 has also been found to be Hyperbaric O2 has also been found to be helpfulhelpful

What you might seeWhat you might see

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

Pilonidal SinusPilonidal Sinus

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

Affects young adults and teenagersAffects young adults and teenagers 3:1 male predominance3:1 male predominance Epithelium lined sinus is usually found to Epithelium lined sinus is usually found to

contain haircontain hair Sinus may become infected, usually after Sinus may become infected, usually after

puberty, with drains openings overlying the puberty, with drains openings overlying the coccyx and sacrumcoccyx and sacrum

Infected abscess may extend to the perianal Infected abscess may extend to the perianal area that may be mistaken for an anal fistulaarea that may be mistaken for an anal fistula

Why me, why now?Why me, why now?

2 Theories of formation:2 Theories of formation: Failure of fusion in the embryo, with Failure of fusion in the embryo, with

entrapment of hair follicles in the entrapment of hair follicles in the sacrococcygeal regionsacrococcygeal region

Result of trauma, with the introduction Result of trauma, with the introduction of hair shafts into the subdermal areaof hair shafts into the subdermal area

SymptomsSymptoms

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

Typical appearance of an abscess Typical appearance of an abscess may be evidentmay be evident

Fever and leukocytosis may be Fever and leukocytosis may be presentpresent

What you might seeWhat you might see

Multiple openings Multiple openings overlying the overlying the sacrum and sacrum and buttocksbuttocks

What you might seeWhat you might see

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

TreatmentTreatment

Antibiotics? Antibiotics? Adjuvant to a surgical procedureAdjuvant to a surgical procedure

I&D I&D Definitive therapy:Definitive therapy:

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

TuberculosisTuberculosis

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

Anal fistula is the most frequent presentationAnal fistula is the most frequent presentation Lesion appears as brownish red papule that Lesion appears as brownish red papule that

can progress to an ulcerating plaquecan progress to an ulcerating plaque Anal fissure in an unusual location that is Anal fissure in an unusual location that is

slow to heal should raise the suspicionslow to heal should raise the suspicion Treatment: anti-TB drugs with resolve Treatment: anti-TB drugs with resolve

usually in 2 to 3 weeksusually in 2 to 3 weeks

STD’sSTD’s

Gonorrhea Gonorrhea ChancroidChancroid Chlamydia Chlamydia Herpes Simplex Herpes Simplex Syphilis: Syphilis:

Chancre Chancre Condylomata lataCondylomata lata

What you might seeWhat you might see

Large perianal Large perianal mucoid warty mass mucoid warty mass composed of composed of smooth-surfaced smooth-surfaced lobuleslobules

NeoplasticNeoplastic

Premalignant LesionsPremalignant Lesions Acanthosis Nigricans-ominous association Acanthosis Nigricans-ominous association

with abdominal cancerwith abdominal cancer Affects face, neck, axillae, external genitalia, Affects face, neck, axillae, external genitalia,

groin, inner thighs, umbilicus, and anusgroin, inner thighs, umbilicus, and anus Grayish velvety thickening or roughening of Grayish velvety thickening or roughening of

the skinthe skin Epidermal papillomatosis, hyperkeratosis, and Epidermal papillomatosis, hyperkeratosis, and

hyperpigmentationhyperpigmentation Treatment is directed to the primary Treatment is directed to the primary

malignant conditionmalignant condition

Premalignant Lesions Premalignant Lesions

LeukoplakiaLeukoplakia Whitish thickening of the mucous Whitish thickening of the mucous

membrane epithelium occurring in patches membrane epithelium occurring in patches of diverse size and shapeof diverse size and shape

Seen in the anal canalSeen in the anal canal Associated with an increased risk of Associated with an increased risk of

malignancy/epidermoid carcinomamalignancy/epidermoid carcinoma Symptoms of bleeding, discharge, and Symptoms of bleeding, discharge, and

pruritic symptoms are the most common pruritic symptoms are the most common complaintscomplaints

Hyperkeratosis and squamous metaplasiaHyperkeratosis and squamous metaplasia

Skin CancerSkin Cancer

Basal Cell CarcinomaBasal Cell Carcinoma Most common cutaneous malignancy, Most common cutaneous malignancy,

extremely rare in the anal areaextremely rare in the anal area Tumors usually between 1-2 cmTumors usually between 1-2 cm Presents with a lump or ulcerPresents with a lump or ulcer Bleeding, pain, pruritis, and discharge Bleeding, pain, pruritis, and discharge

may be presentmay be present Treat with local excision and adequate Treat with local excision and adequate

margins margins APR resection is performed for extensive APR resection is performed for extensive

or infiltrating tumorsor infiltrating tumors

What you might seeWhat you might see

Ulcerating tumor Ulcerating tumor has a pearly has a pearly borderborder

Skin CancerSkin Cancer

Squamous Cell/Epidermoid Squamous Cell/Epidermoid carcinomacarcinoma Tumor appears superficial, discrete, Tumor appears superficial, discrete,

and hardand hard Ulcerates with progressionUlcerates with progression Mets to regional lymph nodes can occurMets to regional lymph nodes can occur Treat with wide local excisionTreat with wide local excision

What you might seeWhat you might see

Ulcerating friable Ulcerating friable tumor is notedtumor is noted

Bowen’s diseaseBowen’s disease

Intraepidermal squamous cell carcinoma Intraepidermal squamous cell carcinoma that spreads intraepidermallythat spreads intraepidermally

Precursor to squamous cell carcinoma of Precursor to squamous cell carcinoma of the anusthe anus

Associated with HPV infectionAssociated with HPV infection Itching and burning, pain and bleedingItching and burning, pain and bleeding Treatment wide local excision with frozen Treatment wide local excision with frozen

section to ensure adequate marginssection to ensure adequate margins

What you might seeWhat you might see

An indurated An indurated erythemato-erythemato-squamous patch squamous patch involving the involving the perianal areaperianal area

Extramammary Paget’s Extramammary Paget’s DiseaseDisease

Large, round, clear-staining cells with large Large, round, clear-staining cells with large nucleinuclei

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

Treatment depends on the presence/absence Treatment depends on the presence/absence or underlying invasive carcinomaor underlying invasive carcinoma Use of retinoid, etretinate, may benefit when Use of retinoid, etretinate, may benefit when

there is no invasive carcinomathere is no invasive carcinoma More infiltrating disease an APR may be needed, More infiltrating disease an APR may be needed,

otherwise wide local excision with grafting otherwise wide local excision with grafting should be adequate for noninvasive diseaseshould be adequate for noninvasive disease

What you might seeWhat you might see

Irregular but well-Irregular but well-marginated marginated erythematous erythematous erosive patch with erosive patch with slightly indurated slightly indurated edgesedges

Extramammary Paget’s Extramammary Paget’s DiseaseDisease

Stage I-localized perianal disease without Stage I-localized perianal disease without carcinoma-tx with wide local excisioncarcinoma-tx with wide local excision

Stage IIA-localized disease without Stage IIA-localized disease without underlying malignancy-tx with wide local underlying malignancy-tx with wide local excisionexcision

Stage IIB-localized dx with associated Stage IIB-localized dx with associated anorectal carcinoma-tx with APRanorectal carcinoma-tx with APR

Stage III-associated carcinomatous spread Stage III-associated carcinomatous spread to regional lymph nodes-tx with APR plus to regional lymph nodes-tx with APR plus chemoradiation, possible radical inguinal chemoradiation, possible radical inguinal node dissectionnode dissection

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