Anal itching

Anal itching may be just an annoyance, or may be so troublesome that it dominates your life. It is usually made worse by warmth, and is often most troublesome in bed. The skin round the anus easily becomes irritated and inflamed. This is because it is difficult to keep the area round the anus clean and dry; the skin is crinkly and traps tiny faecal particles. It is also sweaty and airless, and it may be moist from an anal or vaginal discharge. When it becomes irritated, scratching is a natural reaction, but this damages the skin further – the itch/scratch cycle. Ointments and creams can cause further problems by keeping the area damp.

Although it is very unpleasant, anal itching seldom means anything serious. If you have pain as well as itching, look at the section on anal pain.

Causes of anal itching
Washing too much or not enough. Poor hygiene can be responsible for anal itching, but so can excessive cleaning, especially if you use harsh soaps or a brush.

Leakage of faeces can lead to itching around the anus. Look at the section on faecal incontinence.

Pre-moistened toilet tissues (wipes), bought from chemists and supermarkets, can sometimes cause anal itching. The reason is probably perfume, alcohol or a preservative in the wipes.

Sensitivities and allergies to other chemicals, such as bubble baths and perfumed soaps, may be responsible.

Ointments and creams are notorious causes of anal itching. If you have itching, it is a natural reaction to buy an anaesthetic gel for the anal area. Most of these are labelled ‘for haemorrhoids’ and contain lignocaine, tetracaine, cinchocaine, pramocaine or benzocaine with other ingredients. At first they help, but then the itching may return because you have become sensitive to one of the ingredients in the cream or ointment and they are keeping the area moist. Do not use them for more than 1 week.

Skin conditions, such as psoriasis or eczema, can affect the skin round the anus and cause itching. Piles can sometimes be itchy, partly because of the slimy discharge they produce.

Fungal infections, similar to thrush or athlete’s foot, are another common cause. Fungi love warm, damp and damaged skin, so if you have an itchy anus for any reason and then damage the skin by scratching, fungi can take hold and make it worse.

Sexually transmitted infections are what many people worry about, but are not usually the reason.

• Genital warts (vulva or penis), caused by papillomavirus, thrive in warm, moist conditions such as the skin near the anus and can be very itchy.
• Genital herpes (caused by herpesvirus) can also infect the anus, and causes itching just before the sores appear and also during the healing stage.

Both these viruses are easily transferred to the anal skin on the fingers, and can therefore occur round the anus in anyone. The anus may be the only site of infection; the fact that you do not have genital warts or herpes elsewhere does not rule them out.

Threadworms (pinworms) are tiny worms, about 13 mm long, which live in the lower part of the bowel. They are very common – an estimated 40 million cases in the USA alone. The female worms creep out of the anus at night – how they know it is night, and why they come out only at night, is a mystery. They lay thousands of eggs on the skin of the anus, causing intense itching at night. When you scratch, the eggs lodge under your fingernails, and it is easy to transfer them to your mouth and reinfect your gut by swallowing the eggs.

Certain foods can irritate the anus during defecation. Beer and curry are obvious examples. Some people find that citrus fruits, grapes, tomatoes, coffee or tea can cause problems.

Anxiety tends to make the brain hyper-alert to body feelings that we may otherwise be able to ignore. If you are going through an anxious period, a symptom such as itching can become magnified.

Pleasure. It is worth asking yourself whether you are deriving a perverse, almost erotic, pain/pleasure from scratching the itchy area, which is keeping the irritation going.

How you can help yourself

• Wash the anal area after you have had your bowels open, but not more than three times in a day, using an unperfumed soap and water. Some doctors recommend using aqueous cream (available from pharmacies) as a cleanser. Apply the cream, massage it gently over the area and then rinse off. If you are somewhere where you cannot wash, clean the area with wet tissues (but not with pre-moistened wipes). If you use shower gel to wash your body, make sure you rinse it off very thoroughly so that none remains between the buttocks.
• Dab gently with a soft towel to dry – do not rub. If drying is difficult, use a hairdryer on cool setting.
• Do not put any disinfectant on the skin or in the bath water – this can irritate the skin. Do not use bubble bath – the perfume can irritate. Instead, put a handful of kitchen salt in your bath.
• Keep a cotton-wool ball, dusted with powder, against the anus, inside your underpants or knickers. Use baby powder (not perfumed talcum powder) to dust it. Change it each time you wash.
• Wear loose cotton underwear. Avoid tights and elastic ‘shapewear’ underwear, because they encourage sweating and moistness in the anal area. Avoid anything that keeps the buttocks close together.
• Do not use biological (enzyme) washing powders for your underwear, or perfumed fabric softeners. Instead, use a detergent labelled ‘for sensitive skin’.
• Do not scratch. If you scratch, you damage the skin more and then you itch more. If you feel you really must scratch, try pinching the skin near the anus between your thumb and forefinger through your clothing; this is less damaging than actual scratching. People often scratch at night and do not realize they are doing so. If you think you might be scratching at night, talk to your doctor about taking an antihistamine, keep your fingernails short, wear cotton gloves at night for a while and ask your doctor to check for threadworms.
• Do not use any greasy creams (such as Vaseline) on the area. Greasy creams keep the skin soggy and make the problem worse.
• Be very cautious about anaesthetic creams or ointments. Sometimes they can help by relieving the itch/scratch cycle, but use them only for a short period (about a week).
• Similarly, be very cautious about steroid creams. In the UK, it is possible to buy weak steroid cream (containing hydrocortisone 1% or less) from pharmacies. In the short-term, the steroid reduces inflammation and therefore relieves itching but, in the long-term, it can make the skin thinner and worsen the problem. Resist the temptation to keep on using a steroid cream. Use it for just 1 week, then throw the tube away.
• Try witch hazel – an old-fashioned remedy available from pharmacies. Dab it on twice a day, but stop immediately if it seems to be making the problem worse instead of better.
• Dr James Le Fanu has a column in the Daily Telegraph that acts as a forum for readers’ solutions to health problems. Readers have reported that the inside of a banana skin can relieve itchy skin, including anal itching.
• Feel round the anus for lumps. This may not be easy, because the skin round the anus is normally puckered. A lump might be a wart, a pile or a skin tag alongside an anal fissure.
• Avoid foods that cause excessive flatulence.

How your doctor can help
If you are anxious about being examined by your doctor, look at the section seeing your doctor about an anal problem. Your doctor can check to see whether you have any conditions such as piles (haemorrhoids), fissure, warts, psoriasis, eczema, fungal infections or other infections that need treatment.

• If you scratch at night, an antihistamine taken before you go to bed can help. Antihistamines relieve itching and some also tend to make you drowsy.
• Discuss with your doctor whether you might have threadworms (pinworms). These can be eliminated with mebendazole. You may need several treatments at monthly intervals, because the eggs can persist for several weeks in the environment (Prescriber 2006;17(15):24–32). The other members of your household will also need to be treated, and you should also wash your hands and scrub your nails before eating and after each visit to the lavatory, and wash the anal area in the morning to get rid of any eggs deposited during the night.
• An ointment containing a chemical found in chilli peppers (capsaicin) is an effective treatment for very troublesome anal itching (Gut 2003;52:1233–5), but the researchers used a special very dilute ointment (0.006%) that is not generally available.
• If nothing helps, your doctor might consider referring you to a specialist for injection of a chemical called methylene blue into the anal area. So far, research has involved only a small number of patients, but it worked in 80% (Surgery 2006;24(4):145–7). More research is awaited to find out how long the relief will last.

Useful contacts
American Academy of Family Physicians have two detailed articles on ‘Common Anorectal Conditions’ on their website. The articles are intended for doctors. They explain how doctors examine the anus. They discuss itching, pain, bleeding, lumps, constipation and incontinence of faeces.
www.aafp.org/afp/20010615/2391.html
www.aafp.org/afp/20010701/77.html

Core – the digestive disorders foundation is a UK not-for-profit organization that provides reliable information about all gut problems. They supply a range of leaflets, which are available on the ‘Information’ page of their website (www.corecharity.org.uk) or by post (send a large sae). Write to: Core, Freepost, LON4268, London, NW1 0YT indicating which specific leaflet or factsheet is required. Tel: 0207 486 0341 (this not a helpline).

Pfizer, the manufacturers of Anusol, have a very pleasant website about piles.
www.pilesadvice.co.uk

Wyeth Pharmaceuticals, the manufacturers of Preparation H for piles, have an informative and entertaining website. Look at the symptoms section, which includes a page on ‘Doctor’s examination’ (rectal examination). Careline in UK: 0845 111 0151.
www.preparationh.co.uk