**4.1 Education and lifestyle modifications**

Particularly important in the management of idiopathic pruritus, a set of general strategies and recommendations should be implemented on the initial consultation. These changes are intended to restore the integrity of the perianal skin and prevent further damage when there is no underlying condition responsible for the symptoms. Patients should be instructed to avoid applying any home remedies, over-the-counter products, perfumed wipes, powders, lotions, soaps, etc. Education about gentle cleaning of the perianal area is also important, using water and unscented hypoallergenic soaps, followed by cool air-drying the area or by dabbing with toilet paper. We emphasize the importance of only applying creams and ointments prescribed by one member of our team. A proper balance between dryness and moist of the perianal area is vital. This can be achieved by placing a cotton ball or a makeup removal pad after cleaning, which will aid to keep the moisture of the zone balanced. Patients should also avoid tight-fitting underclothing and synthetic fabrics, especially in warm climates. Maintaining regular bowel habits is very important and controlling stool consistency may reduce the chances of stool leakage and soiling [8]. As part of the initial treatment, we regularly include a standard bowel regimen containing bulking agents, such as fiber supplements (usually powders to be dissolved in water) and stool softener when appropriate. Dietary recommendations for patients affected by pruritus ani have significant value; the elimination of the *pruritogenic foods* from the diet has shown significant improvement of symptoms in up to 48% of patients after 2 weeks (**Table 3**) [8, 15]. We routinely provide patients with a similar list of foods that can trigger or worsen symptoms and instruct them to avoid those at least for the first few weeks.

## **4.2 Topical agents**

If there is persistent symptomatology after 2 weeks of uninterrupted proper treatment, special attention should be placed on excluding other etiologies of secondary

Caffeine-containing products Colas Coffee Tea Energy drinks Citrus fruits and vegetables Carbonated beverages Chocolate Tomato Beer Spicy and acidic foods Refined carbohydrates Nuts

#### **Table 3.** *Food products that contribute to pruritus ani symptoms.*

pruritus. Only after infectious causes have been eliminated from the differential diagnosis, should topical steroids be considered for a limited time. Low-potency topical steroids such as hydrocortisone 1% are preferred as first-line treatment and have shown good results, by decreasing symptoms rapidly and consequently improving the quality of life [15]. The duration of therapy should not exceed 8 weeks since prolonged therapy or the use of potent steroids can be rather detrimental by causing skin atrophy and worsening of anal pruritus. Substance P is a neuropeptide that triggers itching and burning pain; Capsaicin decreases its levels, successfully treating the symptoms in up to 70% of patients when compared to placebo [16]. Topical steroids and capsaicin should be applied over clean and dry perianal skin in the morning and at night. After completion of therapy, this topical preparation should be replaced by a zinc oxide-based skin protectant, such as Calmoseptin® (Calmoseptine, Inc., Huntington Beach, CA). In our practice, we have noticed quick resolution of symptoms by applying vitamin petrolatum and lanolin-based ointments, such as those used in babies' diaper rash (A&D®, Bayer).

In rare cases of idiopathic pruritus ani, symptoms may persist and become intractable, despite all adequate treatment strategies, and after possible secondary causes have been excluded. Fortunately, for this small subset of patients, intradermal injection of methylene blue has been described with acceptable success [7, 8, 17]. Destruction of nerve terminations in the perianal area responsible for the symptoms is assumed as the mechanism of symptomatic relief. The technique description, including concentration and combination of drugs, varies slightly among reports. Full-thickness skin necrosis is a reported complication of this treatment [17, 18]. Our scant experience with this type of treatment has shown good results, however, when we need to use it, it is usually as a last resort.
