We all have embarrassing questions that we’re too afraid to ask. Have no fear. In this weekly series Dr Rakesh Newaj tackles pruritus of the anogenital region.
Pruritus (itching) of the anogenital region is a very common symptom, yet it can take years for the patients to gather enough courage to discuss it with their partners or doctors. The fear of being labelled as having “Crab lice” results in the patient suffering in silence. Instead of seeking help, they tend to take regular breaks to locate a quiet spot, to relieve their distress by scratching.
There are many skin conditions that cause excessive pruritus (itch) in that region and a correct diagnosis and treatment can make a big difference to the patient’s life.
One of the most common diseases that affect the anogenital region is eczema. It can simply present as an ill-defined patch of erythema or can result in lichenification. Though pruritus is almost always present, the typical dry-scaling rash of eczema is rarely seen. This is due to the moisture present in that region. Patients can have severe lichenification and the excoriations can lead to secondary infections. A good history is very important and an eczematous rash on other parts of the body should be taken into consideration. The treatment entails, treating the infection, use of topical corticosteroids, oral corticosteroids and emollients. When lichenification is present, one has to use sedative oral antihistamines to break the itch-scratch cycle.
Contact dermatitis is very common in the anogenital region. It may be divided into irritant and allergic contact dermatitis. Irritant contact dermatitis is commonly seen in infants as diaper dermatitis and in older patients as a consequence of over-zealous cleanliness, urinary incontinence, faecal incontinence as well as bowel diseases such as inflammatory bowel disease. Common allergens include latex, spermicides and creams. However, there is a wide variety of other allergens that can lead to allergic contact dermatitis, via intimate contact. This condition is rarely seen on male genitalia.
Psoriasis is a common disease of the skin that occurs as a result of increased turn-over of keratinocytes. It can also affect the anogenital region leading to severe pruritus. It commonly occurs in the intergluteal cleft and the penile shaft. However, it can also affect the other parts, including the labia majora and the mons pubis. The fact that it lacks the typical thick silvery scales can make it very difficult to diagnose. Good clinical correlation with lesions elsewhere is very helpful. Treatment is difficult as most preparation is very irritating to the skin in that region. Many a time one has to resort to oral medications.
Once felt to rare, genital lichen planus is now recognised to be a frequent cause of vulvovaginal itching, burning and scarring. It does also affect the gland penis and can be very uncomfortable. Lichen planus of the genitalia is more commonly seen in post menauposal women, presenting as vestibular erosion. Dyspareunia and resorption of the labia minora and clitoral hood can be prominent. Erosive vulvovaginal lichen planus is usually accompanied by oral lichen planus. Thus examination of the mouth is very important in patients suspected to have this disease. Patients with erosive and poorly controlled lesions should be regularly followed up due to them having an increased incidence of squamous cell carcinoma.
Lichen sclerosus primarily affect post-menauposal women. However, there is a spike in incidence in girls around 9-10 years old. The disease typically presents as severe pruritus, pain, incontinence or urinary retention. The skin looks depigmented (can be confused with vitiligo), crinkled and thin with visible blood capillaries. It can encircle the vestibule and anus in a figure of eight configuration. Later the fibrosis caused by the disease can irreversibly affect the genital anatomy with resorption of the labia minora and distortion of the clitoral hood. This can lead to pain on intercourse and loss of self-esteem. Male patients can present with a similar rash on the glands penis and the foreskin. Circumcision tends to cure most men.
There are many more skin conditions causing pruritus, which afflict the anogenital skin. Cicatricial pemphigoid and pemphigus vulgaris can lead to blisters and scars. The diagnosis is easier made when typical lesions are present on other parts of the body. However, biopsy and immunofluorescence microscopy can be very helpful. Anal itch can also be very common and a good examination is required. Pinworm infestation should be considered in children with symptoms that get worse at night. An adhesive tape pressed against the perianal skin will reveal the eggs under microscopy. Treatment should be given accordingly.
Haemorrhoids and faecal incontinence can commonly lead to severe pruritus in adults and they should be treated accordingly. Pruritus ani can also be caused by eczema and usually responds to potent corticosteroid creams. A good examination will reveal infective causes like scabies and pubic lice. These cases need to be treated aggressively with treatment of close contacts, as well as the linen.
In conclusion, there are many causes of pruritus of the anogenital region. Examination of skin elsewhere on the body can give good clues to the diagnosis. One should consider idiopathic pruritus syndromes and psychosomatic causes in cases where no skin lesions are seen. These diagnoses are very difficult and a good psychiatric history tends to help. Anogenital skin disease can be very difficult to diagnose thus good clinical experience and biopsies can be very helpful.
This and other embarrassing questions will be answered weekly by sexologist, Elna McIntosh and dermatologist, Dr Rakesh Newaj.
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