How can I differentiate between threadworm infection and other causes of anal itching in a patient?

Differentiating threadworm infection from other causes of anal itching involves a detailed history, focused examination, and consideration of symptom patterns.

Threadworm infection typically presents with intense nocturnal anal itching, which is a key distinguishing feature. Patients often report itching mainly at night, which is less common in other causes of pruritus ani ¹. Additionally, threadworm infestation may be suspected if there are affected household contacts, given its high transmissibility ¹,².

In contrast, other causes of anal itching may have different patterns or associated features. For example, contact dermatitis or atopic eczema may be linked to hygiene practices, use of soaps, creams, or perfumes, and may present with erythema or excoriation on examination ¹. Anal fissures or haemorrhoids often cause perianal pain or bleeding rather than isolated itching ¹. Primary (idiopathic) pruritus ani is considered when no specific cause is identified after thorough assessment ¹.

Physical examination is crucial: in threadworm infection, visible eggs or worms may sometimes be seen around the anus, especially in the early morning, but often the skin shows excoriation from scratching ¹,². Other causes may show characteristic skin changes such as lichenification, inflammation, or fissures ¹. A digital rectal examination may help exclude other pathology like anorectal cancer if red flag symptoms are present ¹.

Additional clues include the impact on sleep (nocturnal itching is more suggestive of threadworm), presence of irritability or decreased appetite in young children who cannot scratch, and the absence of other systemic symptoms ¹.

Laboratory confirmation for threadworm can be challenging; diagnosis is often clinical, supported by history and examination. Skin swabs or stool samples are generally not diagnostic for threadworm but may help exclude other infections ¹.

In summary, the key differentiators for threadworm infection are nocturnal itching, household contacts affected, and typical history and examination findings, whereas other causes of anal itching have different clinical features and associated signs ¹,²[(Heard, 2004)].