Perianal Dermatology/Puritis Ani A Corman Review Justin Blasberg, MD 9/22/05.
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Transcript of Perianal Dermatology/Puritis Ani A Corman Review Justin Blasberg, MD 9/22/05.
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