Perianal Dermatology/Puritis Ani A Corman Review - PowerPoint PPT Presentation

Loading...

PPT – Perianal Dermatology/Puritis Ani A Corman Review PowerPoint presentation | free to download - id: 21eca-OTNhM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Perianal Dermatology/Puritis Ani A Corman Review

Description:

Gonorrhea. Syphilis. Chancroid. Granuloma inguinale. Lymphogranuloma venereum (Chlamydia infection) ... Gonorrhea. Chancroid. Chlamydia. Herpes Simplex ... – PowerPoint PPT presentation

Number of Views:1791
Avg rating:3.0/5.0
Slides: 41
Provided by: justinb
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Perianal Dermatology/Puritis Ani A Corman Review


1
Perianal Dermatology/Puritis AniA Corman Review
  • Justin Blasberg, MD
  • 9/22/05

2
What to look forward to?
  • Description of skin conditions affecting the
    perianal area
  • Review of the differential diagnosis
  • Examples of common and uncommon findings
  • Treatment of the relevant diseases

3
Classification of Skin Conditions
  • Inflammatory
  • Infectious
  • Neoplastic

4
Inflammatory
  • Pruritus ani
  • Psoriasis
  • Lichen planus
  • Lichen sclerosus et atrophicus
  • Atrophoderma
  • Contact (allergic) dermatitis
  • Seborrheic dermatitis
  • Radiodermatitis
  • Behcets syndrome
  • Lupus erythematosus
  • Dermatomyositis
  • Scleroderma
  • Erythema multiforme
  • Familial benign chronic pemphigus (i.e.
    Hailey-Hailey)
  • Pemphigus vulgaris
  • Cicatricial pemphigoid

5
Infectious
  • Nonvenereal
  • Pilonidal sinus
  • Suppurative hidradenitis
  • Anorectal abscess and anal fistula
  • Crohns disease
  • TB
  • Actinomycosis
  • Fourniers gangrene
  • Ecthyma gangrenosum
  • Herpes Zoster
  • Vaccinia
  • Tinea cruris
  • Candidiasis
  • Deep Mycoses
  • Ambebiasis cutis
  • Trichomoniasis
  • Schistosomiasis cutis
  • Bilharziasis
  • Oxyuriasis (i.e. pinworm, enterobiasis)

6
Infectious
  • Venereal
  • Gonorrhea
  • Syphilis
  • Chancroid
  • Granuloma inguinale
  • Lymphogranuloma venereum (Chlamydia infection)
  • Molluscum contagiosum
  • Herpes genitalis
  • Condylomata acuminate

7
Neoplastic
  • Acanthosis nigricans
  • Leukoplakia
  • Mycosis fungoides
  • Leukemia cutis
  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Malignant melanoma
  • Bowens disease
  • Extramammary Pagets disease

8
Pruritus Ani
  • itching in the anal area
  • Symptoms
  • Itching of anal and genital areas
  • Worsening at night
  • May awaken the patient from sleep
  • Scratching with exacerbation of complaint
  • Chronic itching can lead to atrophic or
    hypertrophic skin, with associated nodularity and
    scarring

9
Pruritus Ani Differential
  • Hemorrhoids
  • Anal fissure
  • Scarring from prior anal surgery
  • Constipation/diarrhea
  • Contact dermatitis
  • Mycoses
  • Seborrhea
  • Diabetes
  • Pinworm
  • Psoriasis
  • Neurodermatitis

10
Why me, why now?
  • Increased anal sphincter relaxation in response
    to rectal distension
  • Abnormal rectoanal inhibitory reflexes and a
    lower threshold for internal sphincter relaxation

11
Evaluation
  • Anoscopy and proctosigmoidoscopy
  • Magnifying lens
  • Woods lamp
  • Skin scrapings
  • Stool assessment?

12
What you might see
  • Marked edema with papillomatosis and nodularing
    resulting from chronic abrasion

13
Treatment
  • Injections of local anesthetics, phenol, and
    alcohol
  • Methylene blue
  • Diet modification
  • Sterilization?
  • Antibiotics?

14
Psoriasis
  • Chronic inflammatory disease of the skin
  • Characterized by rounded circumscribed
    erythematous dry scaling patches covered by
    grayish white or silvery white scales
  • Predilection for scalp, nails, extensor surfaces
    or limbs, elbows, knees, and sacral regions
  • Butterfly distribution over the coccyx and sacrum

15
Treatment
  • Moisturizers and agents with salicylic acid
  • Topical corticosteroids
  • Coal tar
  • Anthralin
  • Retinoid
  • Vitamin D3 derivatives
  • Ultraviolet B light
  • PUVA treatment
  • Methotrexate and Cyclosporine

16
Lichen Planus
  • Eruption of small, flat-topped papules with a
    distinct violaceous color and polypoid
    configuration
  • Found in flexor surfaces, mucous membranes,
    genitalia, and perianal area
  • Focal thickening of the granular layer,
    degeneration of the basement membrane and basal
    cells, and a bandlike lymphocytic infiltrate in
    the upper dermis
  • Diagnosis made with skin biopsy
  • Treatment with corticosteroids and occlusive
    dressings

17
What you might see
  • Moderate hyperkeratosis, thickening of the
    stratum granulosum, saw tooth configuration of
    rete ridges, and lymphocytic infiltration

18
Irritant and Contact Dermatitis
  • Irritant Nonallergic reaction following
    exposure to an irritating substance
  • Alkalis, acids, metal salts, dusts, gases, and
    hydrocarbons
  • Allergic (contact) Allergic sensitivity to a
    number of responsible agents, also known as
    hypersensitivity of the delayed type (cell
    mediated hypersensitivity)
  • Dyes, oils, resins, chemicals used on fabrics,
    cosmetics, insecticides

19
Radiodermatitis
  • Secondary to radiotherapy of the rectum, anus,
    and prostate
  • Cell mitosis is arrested skin change results
    from the dosage of radiotherapy
  • Erythema, edema, ulceration, and symptoms of
    burning, itching, or severe pain
  • Treatment with oral Vitamin A 8000IU BID
  • Hyperbaric O2 has also been found to be helpful

20
What you might see
  • Fibrosis of the dermis with sclerosis, atrophy of
    the epidermis, and absence of skin appendages

21
Pilonidal Sinus
  • Common infective process occurring in the natal
    cleft and sacrococcygeal region
  • Affects young adults and teenagers
  • 31 male predominance
  • Epithelium lined sinus is usually found to
    contain hair
  • Sinus may become infected, usually after puberty,
    with drains openings overlying the coccyx and
    sacrum
  • Infected abscess may extend to the perianal area
    that may be mistaken for an anal fistula

22
Why me, why now?
  • 2 Theories of formation
  • Failure of fusion in the embryo, with entrapment
    of hair follicles in the sacrococcygeal region
  • Result of trauma, with the introduction of hair
    shafts into the subdermal area

23
Symptoms
  • Pain, swelling, purulent drainage at and around
    the site of the pilonidal opening
  • Typical appearance of an abscess may be evident
  • Fever and leukocytosis may be present

24
What you might see
  • Multiple openings overlying the sacrum and
    buttocks

25
What you might see
  • Indolent, granulating, nonhealing wound of a
    recurrent (persistent) pilonidal sinus

26
Treatment
  • Antibiotics?
  • Adjuvant to a surgical procedure
  • ID
  • Definitive therapy
  • Excision, excision with grafting or with an open
    wound to close secondarily, cryosurgery, and
    injection of sclerosing agents

27
Tuberculosis
  • Confused for Crohns, actinomycosis, anal
    fistula, colloid carcinoma, sarcoidosis, other
    skin conditions
  • Anal fistula is the most frequent presentation
  • Lesion appears as brownish red papule that can
    progress to an ulcerating plaque
  • Anal fissure in an unusual location that is slow
    to heal should raise the suspicion
  • Treatment anti-TB drugs with resolve usually in
    2 to 3 weeks

28
STDs
  • Gonorrhea
  • Chancroid
  • Chlamydia
  • Herpes Simplex
  • Syphilis
  • Chancre
  • Condylomata lata

29
What you might see
  • Large perianal mucoid warty mass composed of
    smooth-surfaced lobules

30
Neoplastic
  • Premalignant Lesions
  • Acanthosis Nigricans-ominous association with
    abdominal cancer
  • Affects face, neck, axillae, external genitalia,
    groin, inner thighs, umbilicus, and anus
  • Grayish velvety thickening or roughening of the
    skin
  • Epidermal papillomatosis, hyperkeratosis, and
    hyperpigmentation
  • Treatment is directed to the primary malignant
    condition

31
Premalignant Lesions
  • Leukoplakia
  • Whitish thickening of the mucous membrane
    epithelium occurring in patches of diverse size
    and shape
  • Seen in the anal canal
  • Associated with an increased risk of
    malignancy/epidermoid carcinoma
  • Symptoms of bleeding, discharge, and pruritic
    symptoms are the most common complaints
  • Hyperkeratosis and squamous metaplasia

32
Skin Cancer
  • Basal Cell Carcinoma
  • Most common cutaneous malignancy, extremely rare
    in the anal area
  • Tumors usually between 1-2 cm
  • Presents with a lump or ulcer
  • Bleeding, pain, pruritis, and discharge may be
    present
  • Treat with local excision and adequate margins
  • APR resection is performed for extensive or
    infiltrating tumors

33
What you might see
  • Ulcerating tumor has a pearly border

34
Skin Cancer
  • Squamous Cell/Epidermoid carcinoma
  • Tumor appears superficial, discrete, and hard
  • Ulcerates with progression
  • Mets to regional lymph nodes can occur
  • Treat with wide local excision

35
What you might see
  • Ulcerating friable tumor is noted

36
Bowens disease
  • Intraepidermal squamous cell carcinoma that
    spreads intraepidermally
  • Precursor to squamous cell carcinoma of the anus
  • Associated with HPV infection
  • Itching and burning, pain and bleeding
  • Treatment wide local excision with frozen section
    to ensure adequate margins

37
What you might see
  • An indurated erythemato-squamous patch involving
    the perianal area

38
Extramammary Pagets Disease
  • Large, round, clear-staining cells with large
    nuclei
  • Symptoms of ulceration, discharge, pruritis, and
    occasionally bleeding and pain
  • Treatment depends on the presence/absence or
    underlying invasive carcinoma
  • Use of retinoid, etretinate, may benefit when
    there is no invasive carcinoma
  • More infiltrating disease an APR may be needed,
    otherwise wide local excision with grafting
    should be adequate for noninvasive disease

39
What you might see
  • Irregular but well-marginated erythematous
    erosive patch with slightly indurated edges

40
Extramammary Pagets Disease
  • Stage I-localized perianal disease without
    carcinoma-tx with wide local excision
  • Stage IIA-localized disease without underlying
    malignancy-tx with wide local excision
  • Stage IIB-localized dx with associated anorectal
    carcinoma-tx with APR
  • Stage III-associated carcinomatous spread to
    regional lymph nodes-tx with APR plus
    chemoradiation, possible radical inguinal node
    dissection
  • Stage IV-distant mets-tx with standard palliative
    cancer management
About PowerShow.com