Initial management

The aims of pruritus ani management are to relieve the itch and break the itch–scratch cycle. Advise the patient that the condition can be chronic and may need ongoing treatment.

Identify and treat any causes or associated conditions.

Advise the patient on general measures, including:

  • cleaning the perianal area gently using moistened cotton wool
  • using a soap substitute
  • applying a greasy emollient as a barrier
  • promoting a bulkier stool if bowel actions are loose and unformed (eg using bulk-forming laxatives)
  • wearing loose-fitting cotton underwear.

If the skin is weeping, ulcerated or blistered, take a swab to exclude infection. If tinea is suspected, consider skin scrapings for confirmation of dermatophyte infection.

If no treatable cause is found and general measures do not resolve the itch, treat with a topical corticosteroid. Use:

methylprednisolone aceponate (adult, or child 4 months or older) 0.1% fatty ointment topically, once daily, until skin is clear and itch has resolved, or for up to 4 weeks. methylprednisolone aceponate methylprednisolone aceponate methylprednisolone aceponate

If the perianal area is lichenified (skin is thickened), use a potent topical corticosteroid, followed by a less potent topical corticosteroid; see here for recommendations.

Once symptoms have resolved, advise the patient to:

  • continue general measures indefinitely
  • restart the topical corticosteroid at the first sign of itch, and continue until symptoms resolve.

If pruritus ani does not respond to topical corticosteroid treatment:

  • check that the patient is avoiding irritants and allergens
  • check that topical corticosteroids are being applied correctly
  • check adherence to therapy
  • exclude infection.

If no other explanation for lack of response to treatment is identified, reconsider the diagnosis. Refer the patient for dermatologist advice if pruritus ani is severe, or if a more serious diagnosis is suspected.