“We treat people, not just problems.”
John L. Pfenninger, M.D.
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Anal Fissures and Pruritus Ani (“itchy butt”)
Many patients present to our office with symptoms of severe itching around the anus. Others come thinking they have hemorrhoids, because they have experienced bright red rectal bleeding. On physical exam, physicians often find an area that is very sore and irritated with very fine cracks in the skin. These cracks are called fissures. Some fissures are more external on the skin and readily visible. Other fissures are situated more deeply inside. Your physician will be able to determine at the exam which type of fissure you’ve had and what the appropriate treatment is. If yours are the ones that are more visible, then this handout is appropriate for you.
Many people feel that their itching is due to being “dirty down there”. Many times, it is over-cleansing that causes the problem. After having a bowel movement, either wash with a washcloth and warm water or use Tucks Medicated Wipes. A less expensive method is to use baby wipes that do not contain alcohol. Scrubbing is not necessary. Just gentle cleansing.
It is important to use hypoallergenic soaps and shampoos. Many people with this condition have fair skin. They are very sensitive to perfumes and dyes. I like to recommend Aveeno, Oilatum, or Lever 2000 soaps. Anything that states that it is hypoallergenic would probably suffice. For those who really have problems, they will also need to get a hypoallergenic shampoo. We use Envi.
It is important to use only white toilet tissue. The colored dyes in toilet tissue can exacerbate the problem. In addition, white cotton underwear is essential. An extra rinse may be necessary when washing underwear if people really have sensitive skin.
I like to help the immune system as much as possible to resolve the situation. I always recommend a good multivitamin, a total of 1000 mg of vitamin C per day, and 400 IU units of vitamin E. In addition, the herb echinacea (available at food stores and health food stores) taken 2-3 times per day is also helpful.
You should really avoid any offending foods. Common items are coffee, anything spicy, and acidic items. Try eliminating foods to see if it makes things better. If it does not, you can go back to them later.
The final thing that we do to manage this problem is to prescribe a drug called Atarax. It is actually a strong antihistamine, and its only side effect is that it can cause drowsiness. Subsequently, I recommend that people take 25-50 mg an hour before bedtime. Many times, the scratching of the anal area makes the problem worse. It often occurs at night. If we could just eliminate the nighttime scratching, things often improve. One can actually take up to a 100 mg of Atarax at bedtime. Men with prostate problems should go very slowly, because this can sometimes make that worse.
At times, a hydrocortisone cream or suppositories may also be prescribed. One has to be careful not to overuse these, since they will thin out the skin and actually make the problem worse. At times Xylocaine Ointment can also be prescribed. This merely numbs up the area. It does not treat the condition, but again it tries to avoid the itch-scratch cycle which can often make things persist and get worse. For those with fissures that are deeper inside, suppositories may be tried and other ointments. If they do not resolve within three months, surgery may be indicated.
Your physician will tell you which if any of these approaches he wants you to take. Generally, a follow-up visit is required in one month.
Copyright, 2011. John L. Pfenninger, M.D. jw11/10