From the Guidelines
I strongly recommend against prescribing fluocinonide for this patient and instead suggest a trial of conservative care, including fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics, as the initial treatment for anal fissures, as supported by the American Gastroenterological Association medical position statement 1. The patient's symptoms of pain and burning in the anal area, along with the observation of multiple small cuts, are consistent with anal fissures.
- The diagnosis of anal fissure is typically confirmed on physical examination, and the patient's history and physical findings are consistent with this diagnosis.
- Conservative care, including lifestyle modifications such as increased fiber intake (25-30g daily), adequate hydration (at least 8 glasses of water daily), and sitz baths 2-3 times daily for 10-15 minutes with warm water, can help alleviate symptoms and promote healing.
- Topical analgesics, such as lidocaine or capsaicin, may also be used to help manage pain and discomfort.
- If symptoms persist beyond two weeks of treatment, the patient should return for reevaluation, and additional interventions such as topical nitroglycerin or surgical consultation may be considered. The use of fluocinonide, a high-potency topical corticosteroid, may not be the most effective treatment for anal fissures, and its use may be associated with potential side effects, such as skin atrophy and telangiectasias.
- The American Gastroenterological Association medical position statement recommends a trial of conservative care as the initial treatment for anal fissures, with surgical intervention or other treatments considered only if conservative care is unsuccessful 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Fluocinonide Cream USP, 0.05%, Fluocinonide Cream USP, 0.05% (Emulsified Base), Fluocinonide Gel USP, 0.05% and Fluocinonide Ointment USP, 0.05% are generally applied to the affected area as a thin film from two to four times daily depending on the severity of the condition. The patient can be instructed to apply fluocinonide to the affected area as a thin film, 2 to 4 times daily.
- The dosage may depend on the severity of the condition. It is also important to note that if an infection develops, the use of occlusive dressings should be discontinued and appropriate antimicrobial therapy should be instituted 2.
From the Research
Anal Fissure Treatment
The patient's symptoms of pain and burning in the anal area, described as feeling like little burning cuts, are consistent with anal fissure. The patient has a history of hemorrhoids and has tried various treatments, including hydrocortisone cream, suppositories, and Preparation H cream, without improvement.
Treatment Options
- Topical nitroglycerin has been shown to be effective in healing anal fissures, with a healing rate of 75% for chronic fissures and 83% for acute fissures 3.
- However, nitroglycerin is associated with a high recurrence rate and side effects such as headache 3, 4.
- Diltiazem has been shown to be effective in healing anal fissures, with a healing rate comparable to nitroglycerin, but with fewer side effects 5, 6.
- Other treatment options, such as botulinum toxin injections and nifedipine, have also been shown to be effective in healing anal fissures 7.
- A systematic review and meta-analysis found that glyceryl trinitrate was significantly more likely to heal anal fissure than placebo, but was associated with a high risk of headache 4.
Current Treatment
The patient is being prescribed fluocinonide, which is a topical corticosteroid. While corticosteroids may help reduce inflammation and relieve symptoms, they are not typically used as a first-line treatment for anal fissures. The patient's history of trying various treatments without improvement suggests that a different approach may be needed. Consideration of other treatment options, such as topical nitroglycerin or diltiazem, may be necessary to effectively manage the patient's symptoms.