Getting to the bottom of it: essential insights into perianal Crohn’s disease

Perianal Crohn’s disease (pCD), encompassing fistulising and non-fistulising components, is a common and debilitating phenotype of Crohn’s disease (CD). Approximately one in five patients with CD will develop a perianal fistula in their lifetime. In contrast, the prevalence of non-fistulising pCD remains less well characterised; population-based studies report prevalence rates of 6.7%–32.6% for anal fissures, 2.1%–11.1% for skin tags and 6.4%–7.4% for anal strictures. The impact of pCD on people with lived experience can be significant, culminating in poor quality of life, diminished productivity and increased healthcare utilisation. Until recently, pCD has been under-researched, with limited understanding of its pathogenesis and few clinical trials assessing treatment efficacy in this population. In recent years, however, international collaborative efforts have begun to address these gaps; refining diagnostic approaches, defining the molecular landscape and rigorously assessing approved pharmacotherapies using robust, clinically relevant endpoints. Notably, a recent global James Lind Alliance Priority Setting Partnership identified the top 10 research priorities for pCD, signalling a renewed and coordinated effort to address this challenging condition. Emerging data and global collaborative initiatives invite a reappraisal of established paradigms in pCD management. This review summarises recent advances in the field, offering gastroenterologists and surgeons an up-to-date overview of the evolving pCD landscape. It highlights key developments in diagnosis, classification and management, integrated within a holistic framework that incorporates co-designed patient-reported outcome measures.