Clinical Presentation of Cutaneous Lesions

The primary lesions of CD are confined largely to the endoanal skin, the transitional epithelium of the anal canal, and the contiguous 1-2 cm of rectal mucosa. The primary lesion is a painless, midline fissure of the anal canal, which usually remains symptomless and benign. Edematous skin tags arise from the distal margin of superficial fissures. They may be voluminous, with no tendency to decrease. A second and more destructive lesion is a penetrating ulcer which gives rise to fistulas [18]. Fistulous tracts may be low, superficial, or high, long and tortuous, depending on the location of their primary opening in relation to the anal canal. They may form cavities and lead to abscess formation. They may extend to the anal sphincter and have an impact on continence. Finally, anal lesions may lead to stricture formation [19]. Over one-quarter of patients with CD will present with or develop perianal fistula.

Aggressive ulceration is an uncommon form that extends rapidly beyond the perianal skin to involve the perineum and often the vulva [18]. It is usually associated with cavitating endoanal ulcers. Involvement of skin distant to the gastrointestinal tract (metastatic CD) is uncommon, but CD affecting penile and scrotal skin has been described.

Perianal lesions should be carefully assessed and classified (ulceration, fistula, stricture) by physical examination. However examination under anesthesia and modern imaging techniques (endoanal sonography, magnetic resonance imaging) improve the detection and characterization of fistulas and abscesses, and are necessary before defining a therapeutic strategy.

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