Clotrimazole and betamethasone dipropionate cream for anus

Dear Doctor: What can I do about persistent, intermittent rectal itch? I keep the area clean and dry and have tried numerous over-the-counter anti-itch medications, which seem to work for a short time before becoming ineffective. My primary care physician gave me an antifungal prescription (clotrimazole with betamethasone), which my dermatologist said was unwarranted. Your suggestions?

Dear Reader: Kudos to you for being willing to talk about this annoying symptom that most people don’t like to acknowledge, even to their doctors. Be assured: Anal itching (pruritus ani) is a common condition affecting 1 to 5 percent of the population. It’s four times more common in men than in women and occurs predominantly between the ages of 40 and 70.

As for why the condition occurs, it’s generally due to small amounts of fluid stool that irritate the anal region. This may be because the stool itself is loose or because the anal sphincter is abnormally relaxed, allowing leakage. In both cases, fecal material irritates the area beyond the sphincter and causes itching, leading to excessive wiping or scratching of the region. A 1982 study found that 50 percent of people with anal itching normally had loose stools and that 41 percent lost small amounts of stool at least one day a week. Of note, coffee has been found to relax the sphincter in 70 percent of people with the condition.

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Other factors can lead to pruritus ani as well, with fungal infections accounting for 15 percent of episodes. People with diabetes, those who are taking medications that suppress the immune system and those who have used multiple courses of antibiotics are at increased risk of this type of infection.

Bacterial infections can also cause anal itching. So can chemicals from soaps, creams or wet wipes, either through direct irritation or through an allergy to these products. Hemorrhoids and psoriasis can be factors too.

The first step in treating pruritus ani is to eliminate practices that irritate the anal region. Start by washing the area — without soap — to remove any retained material. This can be done with a bidet, or through showering or bathing. Other steps: Use softer, more absorbent toilet paper to make wiping less irritating; make sure the anal area is dry before putting on underwear; and use a zinc oxide cream to help heal the anal area and create a barrier against further irritation.

As for food and drink, not only has coffee been associated with anal itching, but other foods and beverages have also been implicated. These include beer, cola, caffeinated tea, chocolate, citrus foods and drinks, tomatoes, chocolate, peanuts and grapes.

The antifungal preparation that your primary care doctor recommended includes a mixture of antifungal and steroid compounds. The steroid betamethasone eases the itching, and the clotrimazole cream acts against any existing fungal infection. Strong steroid creams can cause skin thinning in the anal region, potentially leading to further irritation and itching.

Take a hard look at the foods and drinks you’re consuming; remove irritating soaps or wet wipes; use water to clean the anal area; keep the area dry; and use a zinc oxide cream to help healing. By following these strict habits, you just might be able to rid yourself of this annoying symptom.

Send your questions to , or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095.

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A thorough local clinical examination by an experienced specialist is generally sufficient to exclude any significant causes of pruritus ani.

Proctoscopy (examination of the anus with a small instrument) is often performed to examine the inside walls of the back passage.

Stool samples are useful in identifying parasitic or other infections.

Biopsies or skin scrapings are sometimes needed to exclude a significant lesion such as cancer or skin condition.

The ultimate goal of treatment is to create dry, healthy, and intact skin.

Medications that thicken stool and create a formed bowel movement minimize leakage or seepage and allow for complete evacuation. Most people can benefit from taking a fibre supplement (Easyfibre, Psyllium husk powder, Metamucil etc). This can be taken in powder or capsule/tablet form, once or twice daily. If stools still remain loose, additional medications may be helpful. Loperamide (Imodium) is an antidiarrheal agent which can thicken or firm stool and help decrease seepage.

Dietary changes are often necessary.  There are several common foods and beverages including coffee, colas, tea, chocolate, tomatoes and beer that are related to pruritus ani.  Avoiding overuse of these items may improve symptoms.  It may be helpful to remove one item at a time from the diet for several weeks.  If symptoms improve, one could try reintroduction of the item in smaller volume and see if there is a limit without producing symptoms.

It will also be important to modify bowel hygiene or cleaning habits. It must be stressed that the anus does not need to be scrubbed or sterilized. Cleaning with plain water rinses is quite helpful. Soaps, perfumes, dyes in tissue or clothing, and baby wipes containing deodorants should be avoided because they can act as irritants. Bathing with Dove® soap is recommended, as it is free of conventional soap; handheld detachable shower heads can be used to clean and wash away any remaining soap residue.  The same effect can also be created with a bidet.

The skin can be dried after cleansing using a hair dryer on low setting. An athlete’s foot powder can also be used to absorb moisture after drying, and a small piece of cotton can be placed between the buttocks and against the anus to help absorb the moisture. Tight fitting, synthetic undergarments should be avoided.

One of the most important aspects of the management of pruritis ani is to avoid trauma to the skin. This means no scratching with hands or dry toilet paper, but is often very difficult to achieve, due to the intense desire to scratch. Many people also scratch during sleep and are not aware of it until they wake to find themselves scratching. It is often recommended to have patients cut their nails and to wear a pair of cotton gloves on their hands at night so they are not able to scratch.

In order to control symptoms, a short course of a steroid ointment may be tried. A weak topical steroid such as 1% hydrocortisone cream used two to three times a day for a short period of time can be effective in relieving symptoms of pruritis. A long-acting topical steroid such as betamethasone may also be effective. Strong steroids or prolonged use can lead to skin atrophy (weakness and thinning) which sometimes worsens pruritis ani.

A skin barrier cream such as zinc oxide may also be helpful in protecting the skin around the anus from irritants. Additional topical agents such as menthol, phenol, camphor, or a combination of them may be helpful.

If there is any concern that there may be an infection, topical antibiotics (gentamicin, clindamycin, or bacitracin) or antifungals (clotrimazole, nystatin) may be added in conjunction with other therapies.

For a small number of patients, pruritis ani can be quite difficult to manage, and it may be difficult to completely relieve their symptoms.  In these patients, it may be beneficial to try topical Capsaicin.  It is believed to work by depressing the feelings or desensitizing certain nerves. The medicine is applied with a very low concentration of 0.006%. 

A very small number of patients find only minimal relief from all attempted treatment options.  These individuals may benefit from injectable therapy. Methylene blue is a dye which can be injected into the skin and may relieve symptoms by causing destruction of the nerve endings.  The methylene blue can be mixed with topical anesthetics and injected into and below the affected perianal region.  Many patients do experience a change in sensation in the injected area; it will also turn the skin in the area blue.  In very rare cases, if it is injected too close to the surface of the skin it may cause some skin breakdown or ulcerations.

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