Anal Itching

A persistent need to scratch your bottom, also called “Pruritus ani”, is a relatively common complaint. There are a number of reasons why anal itching occurs and, more often than not, it can be successfully treated.

• Anal itching may be embarrassing – but it is a common problem seen by doctors
• Too much or too little cleansing can lead to itchiness around the anus
• Some foods and drinks are associated with pruritus ani
• Skin conditions, infections, anorectal disorders, whole-body medical conditions, and drugs are all potential causes

Anal itching: Causes and Treatments

Anal itching is a common condition. The itch, situated in or around your anus, is often intense and may be accompanied by a strong urge to scratch. You may find anal itching to be embarrassing and uncomfortable.

Also called pruritus ani (proo-RIE-tus A-nie), anal itching has many possible causes, such as skin problems, hemorrhoids, and washing too much or not enough.

If anal itching is persistent, talk with your doctor. With proper treatment and self-care measures, most people get complete relief from anal itching.

Symptoms

Anal itching may be associated with redness, burning and soreness. The itching and irritation may be temporary or more persistent, depending on the cause.

A persistent need to scratch your bottom, also called pruritus ani, is a relatively common complaint. There are a number of reasons why anal itching occurs and, more often than not, it can be successfully treated.

In this article, we will discuss the common causes of anal itching, medical treatments, and home remedies.

Fast facts on anal itching

Here are some key points about pruritus ani. More detail and supporting information is in the main article.

• Anal itching may be embarrassing – but it is a common problem seen by doctors
• Too much or too little cleansing can lead to itchiness around the anus
• Some foods and drinks are associated with pruritus ani
• Skin conditions, infections, anorectal disorders, whole-body medical conditions, and drugs are all potential causes

What is Anal itching?

Scratching an itchy bottom can make the problem worse.
Pruritus ani is the medical term for anal itching or itchy bottom. It is defined as intense itching around the anus. Other terms include:

• Anal pruritus
• Perianal itching
• Anorectal itching
• Itchy butt/bum/bottom

The anus is the opening at the end of the gut or digestive system, allowing us to expel solid waste from the body. Pruritus ani refers to itching around the anus.

Anal itching is a symptom, not a disease in itself; it is a surprisingly common problem, which many people are too embarrassed to see their doctor about.

Pruritus ani can happen to anyone but is said to be more common in men than women and more common in adults than children or the elderly.

What can begin as a brief irritation can soon become a chronic problem as the scratch-itch cycle continues. Scratching causes tiny little breaks in the skin that are intensely itchy when the usual moisture and humidity of the perianal area comes into contact with them. This causes more scratching and further tiny itchy cuts.

This scratch-itch cycle is made worse by nighttime scratching when the sufferer is half asleep and unaware that they are scratching, especially as loose nightclothes allow easier access.

When urine passes over the cuts in women, it causes stinging, which is then relieved by over-vigorous wiping with toilet paper, again further damaging the skin.

Often the condition can be cured by a strict no-scratching period, which allows the skin to heal and breaks the cycle. However, a physician should examine the skin and lower bowel to make sure there are no medical problems.

Anal itching (itchy bottom)

An itchy bottom 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 around the anus easily becomes irritated and inflamed. This is because it is difficult to keep the area around the anus clean and dry; the skin is crinkly and traps tiny fecal 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.

Anal itching can occur at any time of life, but seems to be most common between 30 and 50 years of age. It is four times more common in men than in women.

Causes of anal itching

Pruritus ani can have a primary or secondary cause:

• Primary cause – the itching is not the result of another condition
• Secondary cause – the itching has an underlying condition that causes the itching

The list of secondary causes can be collected into broad groups:

• Hygiene – too much or too little
• Skin irritants – such as soaps
• Skin conditions – such as dermatitis and psoriasis
• Anal or rectal disorders – piles, and anal fistulas and fissures, for example
• Infections – including parasitic and sexually transmitted
• Systemic (entire body) medical conditions – including aplastic anemia, diabetes, inflammatory bowel disease, jaundice, leukemia, lymphoma, and thyroid disease
• Foods – dietary irritants, such as chilli peppers
• Drugs – including chemotherapy, colchicine, neomycin, and quinidine

Some foods may make the itching worse, so identifying and avoiding these may help. Examples include:

• Tomatoes
• Spicy foods
• Citrus fruits, such as oranges
• Nuts
• Chocolate
• Dairy products
• Coffee
• Excessive liquids, such as milk, beer, or wine

Often, no cause is identified for the itching – in these instances, the pruritus is labeled idiopathic.

Dermatological (skin) causes

• Prolonged contact with feces can cause irritation.
• People who have fecal incontinence (little or no control over bowel movements) can have leakage, which can cause irritation and itching.
• Persistent diarrhea can cause irritation by nature of the frequency or bowel opening and wiping clean.
• Eczema and idiopathic dermatitis can affect the anal area. This is inflamed skin of no known cause.
• Keloid scar of skin – these are hard, smooth growths that develop when scar tissue develops excessively.
• Scabies – a skin infection.
• Allergic dermatitis may be due to allergic reactions to creams, lotions, bubble baths, washing powders, wet wipes, etc. Sometimes, creams that are used to soothe or treat the itch cause a worsening of the problem because of the chemicals they contain.
• Yeasts (thrush, candida), bacteria (beta hemolytic streptococci, staph aureus) and viruses such as the genital wart virus (HPV) can cause skin infections in the anal region.
• Pinworm is a very common cause of itchy bottom in children and families with young children. Female pinworms lay eggs in the folds of the anus; this can cause itching.
• Hookworm infection – these are parasites that can affect the lungs and small intestine.
• Small skin tags – may hide fecal residue or trap moisture, causing itching.
• Some sexually transmitted infections can cause itching in the region.
• Psoriasis is a chronic skin condition; it can also affect the perianal area.
• Proctitis – the inner lining of the rectum becomes inflamed.

Gastroenterological (bowel) causes

• Hemorrhoids (piles) can cause local irritation
• Anal cancer should always be considered and checked for
• Inflammatory bowel disease can cause frequent diarrhea and irritation

Systemic (whole body) causes

• Diabetes
• Liver disease
• Thyroid problems
• Blood cancers
• Anemia
• Rheumatological diseases
• Autoimmune diseases

Psychological (mind) causes

Anxiety, stress, and depression are all known to make anal itching worse.

Leading 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, because prolonged contact with substances in the faeces causes irritation of the skin. About half of all people with anal itching tend to have loose faeces. Look at the section on faecal incontinence for more information.

Anal conditions (particularly piles) can have itching as one of their symptoms, partly because of the slimey discharge they produce. Look at our section on piles for more information.

Pre-moistened toilet tissues (wet-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, or a condition called lichen sclerosis, can affect the skin around the anus and cause itching

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 and other 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 herpes virus) 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 around 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. Various bacteria (such as some staphylococci or streptococci) can cause anal itching; the skin will be red and inflamed, and needs antibiotic treatment.

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. If several people in the family have anal itching, threadworms might be the cause.

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.

Tight trousers or underwear, especially synthetic and elasticated fabrics, retain heat and sweat, which worsens itching.

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.

Tests and Diagnosis

Your doctor may be able to diagnose the cause of your itching simply by asking you questions about your symptoms, medical history and personal habits. If pinworms are suspected, your doctor may suggest doing a test for pinworms. He or she may also give you a physical exam, including a digital rectal exam.

If the cause of your itching isn’t obvious, your doctor may refer you to a skin specialist (dermatologist) or a doctor who specializes in treating rectal and anal problems (proctologist). He or she may do other tests, such as proctoscopy or colonoscopy to view more of the digestive tract. But it’s possible the cause of the itching may never be identified.

The first time someone presents the problem of anal itching to their doctor, the consultation will start with a number of questions. This will help to see if the itching is due to local skin problems, or a more general problem with the whole body.

The doctor may:

• Ask about the duration and pattern of the itch
• Explore dietary intake and hygiene practices to see if there is inadequate or excessive washing, or use of creams, perfumes, or soaps
• Evaluate how severe the itch is, and work out its impact on life

Other information will help to pin down a possible cause for the pruritus ani:

• Is there a relevant past medical history, such as anorectal surgery, hemorrhoids, or diabetes?
• Has there been any urinary or fecal incontinence?
• Is there blood on toilet paper, anal pain, or lumps to indicate hemorrhoids?
• Has there been any bloody diarrhea and abdominal cramps (suggesting inflammatory bowel disease)?

A physical examination may follow so that the doctor can see how the problem looks, checking for signs of skin cracking or inflammation and any bleeding around the anal area. Chronic scratching can cause thickened pale skin.

A visual check may also reveal hemorrhoids, anal fissures, or eczema, for example. It may simply reveal soiling as the issue. The anus and rectum should also be examined for evidence of cancers.

An internal examination will be performed by the doctor – by inserting a gloved and lubricated finger through the anus into the rectum.

This is known as a digital rectal examination; it helps to diagnose hemorrhoids or constipation as well as rule out suspected cases of bowel cancer, which are rare.

The doctor may ask you to clench your bottom, as a test of the anal sphincter, or ask you to push, as a way of looking for internal hemorrhoids that get pushed through to the outside (prolapse).

The whole body should be checked for other conditions that may have pruritus ani as a cause. Investigations for pruritus ani include:

• Swabs if infection is suspected
• A biopsy if there is any abnormal skin
• Stool cultures if there is any diarrhea
• Routine blood tests to check blood count, renal, liver, thyroid, diabetes, and inflammatory markers

Anal Itching Treatments

Treatment of anal itching depends on the cause of the problem. It may include taking self-care measures such as nonprescription anti-itch cream or treating an infection or hemorrhoids.

If your symptoms are worse at night, your doctor may prescribe an oral antihistamine until an anti-itch cream takes effect.

With proper care most people experience relief from anal itching. See your doctor if the itching persists.

Below are some practical tips to help with the treatment and prevention of an itchy bottom:

Home remedies and self-care

• Avoid highly seasoned and spiced foods, and maintain a regular bowel habit
• Keep the anal area clean after emptying the bowel
• Avoid medicated, perfumed, or deodorant soaps – use only plain warm water for cleaning, aqueous cream, or emollients
• Use moist toilet tissues instead of paper
• Avoid allowing the anal area to stay moist, and dry it gently by dabbing, not by rubbing
• Use drying powders, but not medicated or scented ones
• Avoid scratching the area, which creates further trauma and makes the problem worse
• Wearing socks or cotton gloves on the hands may reduce the harm from unconscious scratching for people who find they have been unable to resist overnight scratching
• Wear loose, breathable clothing, avoiding materials such as acrylic and nylon, which trap sweat

Understanding and educating about the scratch-itch cycle is very important. The skin must be allowed to heal to reduce the irritation that causes the scratching. Avoiding irritating soaps and creams, and keeping the skin cool, dry, and clean is essential.

Fingernails should be kept short, and intense itching soothed with cool water on cotton wool balls.

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 just water or an unperfumed soap. 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 containing perfume, alcohol or other irritants). If you use shower gel to wash your body, make sure you rinse it off very thoroughly so that none remains between the buttocks. It is best to wash in a squatting position using a shower head or bidet, so that any faecal material between the buttocks is washed away.
• 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. Zinc oxide cream (from pharmacies) can be soothing if the skin has been damaged by scratching.
• 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 around the anus for lumps. This may not be easy, because the skin around 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 (wind).

Lifestyle and home remedies

Prevention of anal itching mainly involves washing properly, keeping the area clean, cool and dry, and avoiding irritants. If you already have anal itching, try these self-care measures:

• Cleanse gently. After bowel movements, clean the area with plain water or mild soap. It may help to use moist cotton balls or a small squeeze bottle of water. Don’t scrub. The goal is to keep the area clean without further irritating the skin.
  When traveling by air, take an empty squeeze bottle that you can readily fill with water in bathrooms.
• Dry thoroughly. After cleansing, pat the area dry with toilet paper or a towel. Or use a hair dryer set on low. Unmedicated talcum can help keep the area dry. Avoid cornstarch powder, which can foster bacterial growth. You could place a moistened or dry cotton ball against the anus to help absorb moisture. Replace it as needed.
• Don’t scratch. Scratching further irritates your skin and leads to persistent inflammation. You may find some relief by applying a cold compress to the area or taking a lukewarm bath. Trim your nails short and wear cotton gloves while you’re sleeping to help prevent scratching.
• Wear cotton underwear and loose clothing. This helps keep the area dry. Avoid wearing pantyhose and other tightfitting garments because these can trap moisture.
• Avoid irritants. Avoid bubble baths, genital deodorants, perfumed soaps, moist wipes, witch hazel products and other items that might irritate the anal area. Cut back on or avoid coffee, cola, alcohol, citrus fruits, chocolate, spicy foods, tomatoes and foods that may cause diarrhea. Avoid overuse of laxatives.
• Apply ointments or gels. Protect your skin from moisture by applying a thin layer of a zinc oxide ointment (Desitin, Balmex) or petroleum jelly. You could also use a 1 percent corticosteroid cream (Cortaid, Preparation H Anti-Itch Cream) two or three times a day to relieve itching. But don’t use this type of cream for more than two weeks because of possible side effects, such as thinning of the skin.
• Maintain regular, firm bowel movements. If soft stools or frequent bowel movements are a problem, gradually adding fiber to your diet may help. Fiber supplements, such a Metamucil or Citrucel, also may help.

How your doctor can help

If you are anxious about being examined by your doctor, look at the section on 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). They look like small threads of slow-moving white cotton. These can be eliminated with mebendazole or piperazine. The treatment has to be repeated after 14 days, because the eggs can persist for this length of time in the environment. The other members of your household will also need to be treated. 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, 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 the itching improved in most patients and disappeared completely in half. More research is awaited to find out how long the relief will last.

When to see a doctor

Most anal itching doesn’t require medical care. See your doctor if:

• Anal itching is severe or persistent
• You have anal bleeding
• The anal area seems to be infected
• You can’t figure out what’s causing a persistent itch

Persistent anal itching may be related to a skin condition or other health problem that requires medical treatment.

Preparing for your appointment

Often you won’t need to see a doctor about anal itching. If the itching persists even after taking self-care measures, bring it up with your primary care doctor. He or she may refer you to a skin specialist (dermatologist) or a doctor who specializes in treating rectal and anal problems (proctologist).

Here’s some information to help you get ready for your appointment.

What you can do

Before your appointment make a list of:

• Symptoms you’ve been having, including any that may seem unrelated to anal itching
• How long you’ve been experiencing your symptoms
• All medications, vitamins and supplements you take, including the doses
• Questions to ask your doctor

For anal itching, some basic questions to ask your doctor include:

• What’s the most likely cause of my symptoms?
• What tests do I need?
• Is this problem temporary?
• What treatments are available? Which do you recommend?
• Do you think I need to see a specialist?
• Do you have any brochures or other printed material that I can take with me? What websites do you recommend?

What to expect from your doctor

Your doctor is likely to ask you a number of questions, such as:

• Have your symptoms been continuous, or do they come and go?
• How severe are your symptoms?
• Have you had recent changes in your bowel movements, such as diarrhea?
• What type of soap or other products do you use on your body?
• Does anything seem to improve your symptoms?
• What, if anything, worsens your symptoms?
• Have you noticed any other changes in your general health?
• Are others in the home experiencing a similar itch?

What you can do in the meantime

Cleanse the anal area gently immediately after bowel movements and dry thoroughly. Wear cotton underwear and loose clothing. Try not to scratch.