Anal itching
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i4931 (Published 04 November 2016) Cite this as: BMJ 2016;355:i4931All rapid responses
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Pruritus or pruritis? This was spelt "pruritus" in the article and "pruritis" in the WHAT YOU NEED TO KNOW section and the HOW PATIENTS WERE INVOLVED IN THE CREATION OF THIS ARTICLE paragraph.
I have to agree that "pruritus" is the way I have always spelt this - I must have been having a senior moment in my previous response, perhaps after seeing the other spelling in the print version! I am grateful to Chandrasekaran for raising this.
Competing interests: No competing interests
The 10 minute consultation by Sahnan et al (1) was meant to be an educational piece notwithstanding some critical responses it evoked among the readers. The perplexing issue to me was the use of the term "pruritis" to describe itching. This misnomer is not new to medical literature and is characteristic of non-dermatology journal publications and of authors belonging to English speaking countries(2). It would be worthwhile to have a debate on what is the correct word to describe itching: is it pruritis or pruritus? Until this confusion on the nomenclature is resolved, people like me belonging to non-English speaking countries will continue to be perplexed.
References:
1. http://www.bmj.com/content/355/bmj.i4931.
2.http://jamanetwork.com/journals/jamadermatology/fullarticle/209509.
Competing interests: No competing interests
Sahnan et al comment that "Most patients have idiopathic itching and can be managed in primary care" and "most patients do not consult a doctor". Hence this article is based on the minority who find their way to secondary care. From the GP point of view, the main problem here is that he is a lorry driver, many of whom spend many hours sitting in their (the vast majority are male) cabs. This creates a warm moist perianal area, ideal for causing pruritis ani. Advice in Primary Care would be given on suitable "breathable" seating and clothing in that area to minimise the risk of recurrence, once treated. Even moving the bottom frequently is useful, rather than sitting still in one place for hours at a time. Pruritis ani is almost an occupational hazard for long distance lorry drivers.
Perhaps some Primary Care input would have helped this article - which is excellent for the minority that reach hospital outpatients.
Also, as others have stated, the photos are mislabelled on BMJ.com, although they are correct on the print version!
Competing interests: No competing interests
Thank you for the concise summary article on anal itching, published in the BMJ 5th November 2016 edition. Peri-anal dermatoses and pruritus-ani are common and socially embarrassing conditions that are often poorly managed. There is a lack of published data on the role of patch testing in patients with these conditions.
We would like to draw attention to the authors and your readers about the importance of patch testing in this group of patients. Our study, the largest reported case series, in the Cutaneous Allergy Clinic, at St John’s Institute of Dermatology, recently published in Contact Dermatitis, 2016, 74, 295-319, strongly recommends patch testing in all patients with peri-anal dermatoses or pruritus ani, as approximately 20% of them will have relevant allergens to be avoided.
Testing with the European baseline series, other relevant series and the patient’s own products should be undertaken. In our case series, methylchloroisothiazoline/ methylisothiazoline (MCI/MI) was the most common allergen implicated in pruritus ani, frequently from the use of wet wipes and other toiletries.
Apart from wet wipes, clinicians should ask about other suspected triggers for peri-anal disease, such as sanitary towels, medicaments (including haemorrhoid medications and suppositories), toiletry sprays/deodorants, and clothing.
Kind regards,
Dr. Mohammed J. Abu-Asi and Dr. Jonathan M. L. White
Cutaneous Allergy Clinic, St John’s Institute of Dermatology,
Guy’s & St Thomas’ Hospitals NHS Foundation Trust,
London, SE1 9RT, UK
E-mail: mohammed.abu-asi@doctors.org.uk
Competing interests: No competing interests
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Few concerns !
1. The picture projected as lichen planus seems more like condylomata / anal warts
2. The picture projected as anal wart seems more like a perianal hematoma.
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Although I am specialized in neither dermatology nor surgery, I am highly sceptical about the figure legends found in this article. I would diagnose Figure 1 as lichen sclerosus, Figure 2 as anal warts and Figure 3 as a thrombosed haemorrhoid. Could this be a mix-up?
Kind regards,
Roald Lambrechts, the Netherlands
Competing interests: No competing interests
Personally I find the laundry detergent factor very important and no doubt unsuspected by many sufferers and perhaps their doctors too. This is worse when sitting -- e.g. on a long journey or even by long periods of reading or sitting for desk/keyboard tasks. This was not something I learned as a medical student!
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Thank you for the concise summary article. I think the captions of the photographs have been mixed. Please review.
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Re: Anal itching
May I add advice to your article on 5th November by Sahnan et al?
For itching of unknown cause, often in the elderly, scrupulous hygiene is essential, so if necessary the anal area should also be cleaned with plain water after every micturition, especially after exercise. In the absence of a bidet, this requires some toilet paper soaked in preferably warm water, which may have to be taken into the cubicle, followed by gentle drying. When at home sometimes a hair dryer can be carefully used to dry the area thoroughly.
The only emollient should be simple aqueous cream or ointment, none with added chemical or fragrances, and should be applied especially at night.
Competing interests: No competing interests