Step 1: Understand the itch-scratch cycle
Itchy butt is an incredibly frustrating condition to have and treat. It is also common! One in twenty adults will have this in their lifetime, with many suffering for years. If you’ve ever had a dog have an issue with scooting, the principles of managing that issue is remarkably similar.

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Understanding how the itching comes about and is triggered will help more than any medication your doctor can give you.

Google an image of ‘Pruritis Ani’. In this photo, you will likely see a typical shield shaped area (this is the area where the buttocks are opposed when standing, leading to moisture) with central whiter skin which is abnormally thickened, and surrounded by red (inflamed) skin. These are features of the itch-scratch cycle. The fragile skin is irritated by some trigger (there are more than 150 triggers) and becomes inflamed and cracks, like a motor mechanic’s calloused hands. The cracked skin leaks moisture, which itches and irritates the skin further, leading to further scratching. The long term irritation and scratching cause the skin to thicken as a protective mechanism, which leads to further cracking.

This cycle is self perpetuating and to fix your anal-itching you have to break this cycle.

Step 2: Treat underlying medical causes
Whilst a large number of patients have an itchy bottom without an easily identified cause, there are a number of known medical conditions that need to be considered.

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• Bowel cancer. This does not commonly cause itching, but in many countries is the second or third most common cause of cancer death. If you have a bowel or problem down there of any kind, it’s important to have a colonoscopy if you are over the age of 45.
• Fissures and Haemorrhoids. Anything that contributes to moisture around the butt can worsen itching, and both of these can be treated by a doctor.
• Worms. If you have young children, or anyone in the family who has had worms, this raises the likelihood of worms. This is easily treated.
• Fungal infections. The most common is tinea pedis – also known as athlete’s foot.
• Skin conditions like psoriasis. This is usually obvious as there are further areas of skin around the body affected. These should be treated by your dermatologist.
• Anal-Leakage

All of these can be treated by a doctor, and will go a long way to improving your symptoms.

Step 3: Optimise bowel function and toileting behaviour.
Faeces is highly irritant to the skin. It may be related to its pH, other components, or just its moisture content. In any event, any person with an itchy butt needs to optimise bowel function. The rectum and butt are designed to deal with a play dough like stool best. Suboptimal poop type, especially those which are too loose or pasty are going to contribute to skin problems around the butt, as any parent who has had a kid with a nappy rash will attest.

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If you have an irritable bowel, see a dietician to find the triggers in your diet that are causing loose bowel movements. A fibre supplement like psyllium or flax seed will help optimise the texture of your bowel motions.

Conventional toilet paper is an odd western convention. Not only is it abrasive, it’s really inefficient at cleaning up all the faeces.

The worst outcome for an itching butt is to be subjected to several loose bowel movements daily, partially cleaned up by rough toilet paper, likely leaving stool residue and moisture as well as sandpapered, irritated skin.

A single daily formed play dough like stool, followed by a water rinse and air dry is optimal. The Japanese do it best with rinsing toilet products like this or this. If you have an itchy butt and happen to be renovating your bathroom, install one of these. There are cheaper versions too like this or this.

Step 4: Minimise lotions, potions, soaps and medications
Having stressed the importance of keeping the skin around the butt clean, there is a problem in the other direction too, often labeled over-hygiene.

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Many patients develop allergies, called ‘contact dermatitis’ to one of the chemical ingredients in soaps or washes available. Keep cleaning to using simple water only where possible.

Commonly prescribed medications are worth a special mention. Many are made with two common ingredients: local anaesthetic creams and steroid preparations. The local anaesthetic acts as a numbing agent, and the steroid acts as a powerful anti-inflammatory.

Local anaesthetic agents, recognised by the use of the letters ‘caine’ at the end (e.g. lignocaine, cinchocaine) cause a contact dermatitis with long term use, and steroid preparations, recognised by the use of the letters ‘sone’ at the end (hydrocortisone, betamethasone), thin the skin down, making it more fragile, and worsen the problem long term. These medications can be useful in treating dermatitis, but aim to use them for as little time as possible.

Step 5: Keep skin cool, dry and protected
Skin itches when it is hot, moist and irritated. Many sufferers attest that itching is worse at night, after having had a shower (moisture) and getting under a warm duvet in bed (heat). For those in cold climates, if you are itching badly at night, go outside with no underwear, spread your cheeks and count the seconds until your symptoms disappear.

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Cool, dry, protected skin rarely itches. Moist, irritated skin itches like crazy.

This makes a lot of sense when you think about the way the body registers itch. From the brain’s perspective, itching communicates some sort of tissue damage. Keeping the skin dry and protected from irritants will reduce the number of ’tissue damage’ messages sent to the brain.

The interesting thing about these kinds of messages is that they can be drowned out by noise. Why does a massage help a sore back? Why does a heat pack feel good for period pain? Why is an ice pack is good for a sprained ankle? What is going on here?

This phenomenon is called counter-irritation. The nerve pathways are like telegraph poles and can only process sensation at a certain rate. Both pain and itch can be blocked by providing background noise.

We can exploit this to block itching too. There are a limited number of known counter irritants, and these can be used to block itching. Deep heat and Tiger balm are good examples. The key with skin around the butt is that it is sensitive. Getting the level of background noise just right is the tricky part.