Changes

September 2026 — reviewed. A literature search was conducted in August to September 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. There has been some minor restructuring to the topic. No major changes to clinical recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Assess a person with pruritus ani.
• Identify and manage secondary causes of pruritus ani, if possible.
• Relieve the symptoms of pruritus ani.
• Refer a person with pruritus ani to secondary care, where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Pruritus ani is a skin condition characterized by the sensation of perianal itching or burning. 
  • It is a symptom, not a diagnosis, and it can be categorized as primary (idiopathic) or secondary (has a specific underlying cause).
  • It is considered 'chronic' if it has been present for more than 6 weeks.

 [PCDS, 2022; Jakubauskas, 2023; Albuquerque, 2026; Marino, 2025]

What causes it?

• Pruritus ani may be:
  • Primary (idiopathic) — there is no disease-specific cause.
  • Secondary — a causative underlying disease can be identified.
• The literature is contradictory about which is the more common type.
• Primary (idiopathic) pruritus ani is believed to be usually associated with faecal contamination of the perianal skin, which may lead to a vicious cycle of itching and scratching. Subsequent effects may be amplified by too much or too little cleaning.
• The itch-scratch cycle may then lead to inflammation, excoriation and skin maceration, which may be followed by hypertrophy and then lichenification.
• Secondary pruritus ani can be caused by a great number of underlying disorders, including:
  • Skin conditions, including:
    • Primary conditions, such as atopic eczema, Bowen's disease, lichen planus, lichen sclerosus, psoriasis, seborrhoeic dermatitis, and Paget's disease.
    • Secondary conditions, such as allergic contact dermatitis (for example, due to soaps and perfumes).
  • Infections and infestations, including:
    • Bacterial infections (for example, staphylococcal or streptococcal).
    • Fungal infections (for example, Candida or other fungal infections).
    • Viral infections (for example, papillomavirus or herpes simplex).
    • Parasitic infestations (for example, threadworms [common in children] or scabies).
    • Sexually transmitted infections (STIs; for example, gonorrhoea or syphilis).
  • Colorectal and anal pathology, including anal fissure or fistula, haemorrhoids (prolapsed internal or external), perianal skin tags,  inflammatory bowel diseases, rectal prolapse, chronic constipation or diarrhoea, and anorectal cancer.
  • Systemic disease, including diabetes mellitus, kidney or liver disease, leukaemia, lymphoma, anaemia (aplastic or iron deficiency), and thyroid disease.
  • Menopause, causing dryness and atrophic change of the anogenital area.
  • Psychological disorders, including depression and anxiety.
  • Drugs, including:
    • Systemic drugs, such as antibiotics (tetracycline and metronidazole), corticosteroids, immunosuppressants, colchicine, and peppermint oil.
    • Topical drugs, such as local anaesthetics, glyceryl trinitrate, and topical corticosteroids — may result in allergic contact dermatitis.
  • Foods and drinks, including spicy food, citrus fruits, tomatoes, nuts, dairy products (including milk and chocolate), coffee and other caffeinated drinks, beer, and wine.
  • Clothing, such as clothes that increase moisture retention or sweating. Residue remaining after the use of biological enzyme-based laundry detergents may also result in itch.

[Ortega 2019; PCDS, 2022; Jakubauskas, 2023; Slagle, 2023; Albuquerque, 2024; Newman, 2026]

How common is it?

• Pruritus ani is thought to affect up to 5% of the population, although the true incidence is not known, and this may be an underestimate, as not all those affected seek medical attention. It is:
  • About four times more common in men than in women.
  • Most common in people aged 40–60 years, although it can occur in all age groups.

[Ortega 2019; PCDS, 2022; Jakubauskas, 2023; Albuquerque, 2024; Marino, 2025]

What is the prognosis?

• Where a specific underlying cause is diagnosed and treated, pruritus ani usually resolves or significantly improves.
• In idiopathic pruritus ani, more than 90% of people respond well to conservative treatment. 
• In some people, the condition may be long-lasting and may be associated with complications. 

[Jakubauskas, 2023; Newman, 2026]

What are the complications?

• Persistent scratching can tear the perianal skin, leading to:
  • Eczema.
  • Lichen simplex.
  • Hypertrophic skin (nodularity and scarring).
  • Ulceration.
  • Excoriation.
  • Secondary infection, such as Staphylococcus aureus infection.
• Chronic itch can result in:
  • Psychological problems, such as feelings of embarrassment and stigma, depression, and anxiety.
  • Insomnia, with daytime tiredness and a reduced quality of life.

[Ortega 2019; Jakubauskas, 2023]

How should I assess someone with pruritus ani?

• Take a detailed history to identify a secondary cause for the itch. Ask about:
  • The duration and pattern of the itch, including whether:
    • It occurs mainly at night — possible threadworm infestation. See the CKS topic on Threadworm for more information.
    • There are household contacts affected — possible scabies infestation. See the CKS topic on Scabies for more information.
    • The itch is related to trigger factors, such as certain clothing, stresses, or foods. 
  • The severity of the itch and the impact on mood, sleep pattern, and social life.
  • Hygiene practices, including washing regimen and the use of creams, perfumes, or soaps — possible contact dermatitis or atopic eczema. See the CKS topics on Dermatitis - contact and Eczema - atopic for more information.
  • Bowel habits, including the presence of 'red flag symptoms' for anorectal cancer and family history. See the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for detailed information on when to suspect anal or colorectal cancer.
  • Other symptoms experienced:
    • Perianal pain may be due to an anal fissure or haemorrhoids. See the CKS topics on Anal fissure and Haemorrhoids for more information.
    • Rectal bleeding may be due to haemorrhoids or anorectal cancer. See the CKS topics on Haemorrhoids and Gastrointestinal tract (lower) cancers - recognition and referral for more information.
    • Anal discharge may be due to infection, infestation, or haemorrhoids.
    • Irritability, sleep disturbance, and decreased appetite may be seen in children who are too young to scratch.
  • Comorbidity — identify any relevant medical history such as inflammatory bowel disease, faecal incontinence, skin conditions (such as psoriasis, eczema, skin malignancy, allergies), diabetes, renal failure, haematological conditions, sexually transmitted diseases, thyroid disorders, and any medication.
  • Dietary habits — identify consumption of food or drink which may contribute to or cause pruritus ani, such as alcohol, caffeine, and spicy foods.
  • Family history — others in the household with pruritus (which might suggest threadworms or scabies), and family history of colorectal tumours (which might increase suspicion of malignancy as the underlying cause).
• Examine the person. Offer a chaperone. Ask them to lie comfortably in a lateral position, and gently part the buttocks. 
  • An external examination may reveal the cause of the itch (for example, haemorrhoids, anal fissure, anogenital warts, or perianal eczema) or conditions which can exacerbate the issue by making the area more difficult to keep clean (such as haemorrhoids, anal skin tags and warts, or faecal incontinence/soiling).
  • The appearance of the perianal skin will vary depending on the intensity and duration of pruritus ani.
    • In mild cases, there may be minimal erythema.
    • In severe cases, the skin may be inflamed, excoriated, and/or fissured.
    • In chronic cases, the anal ring may have a shiny appearance, and there may be lichenification of the skin due to repeated scratching.
  • Perform a digital rectal examination in adults (if this is appropriate and possible without causing pain) to exclude any underlying pathology, such as a perianal mass suggesting anorectal cancer. Further examination with a proctoscope will usually also be required, if possible, to examine for anorectal haemorrhoids, fistulas or fissures.
  • Some patients may require a more thorough skin examination if an underlying skin condition seems likely. There may be more widespread skin changes, such as in the groin or skin folds for infectious or atopic conditions, or jaundice if there is a hepatic cause.
• Investigations may be required depending on the findings on history and examination.
  • A skin swab for microscopy, culture, and sensitivities is usually appropriate.
  • A tape test may be helpful if threadworm is suspected. See the CKS topic on Threadworm for more information.
  • Blood tests, or referral for lower gastrointestinal investigation or skin biopsy and patch testing may be necessary if an underlying condition is suspected.
• If no cause for the itch is identified, a diagnosis of primary (idiopathic) pruritus ani is likely. 

Scenario: Management

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of pruritus ani.

Search dates

July 2021 - September 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• ("pruritus ani" or "idiopathic pruritus ani").ti,ab,kw.
• exp Pruritus Ani/

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.