What are the recommended topical treatments for anal fissures?

From the Guidelines

Topical calcium channel blockers, such as diltiazem (2%) or nifedipine (0.2-0.5%), are the recommended first-line treatment for anal fissures, as they have been shown to be effective in promoting healing and have fewer side effects compared to nitroglycerin ointment. According to the most recent and highest quality study 1, calcium channel blockers have a healing rate ranging from 65 to 95% and are associated with a remarkable cost-effectiveness compared to other non-operative treatments.

Key Points to Consider

• Topical treatments for anal fissures should be accompanied by conservative measures, including:
  • Increased fiber intake (25-30g daily)
  • Adequate hydration (8 glasses of water daily)
  • Sitz baths (10-15 minutes in warm water 2-3 times daily)
  • Stool softeners if needed
• Patients should avoid straining during bowel movements and maintain good anal hygiene
• If symptoms don't improve after 8-12 weeks of topical therapy, surgical consultation may be necessary

Treatment Options

• Nitroglycerin ointment (0.2-0.4%) can be used, but it may cause headaches and has a lower healing rate compared to calcium channel blockers
• Botulinum toxin injections can also be used, but the evidence is limited and it may not be as effective as calcium channel blockers
• Manual dilatation is not recommended due to the high risk of incontinence and other complications 1

Recommendation

The use of topical calcium channel blockers, such as diltiazem (2%) or nifedipine (0.2-0.5%), is the recommended first-line treatment for anal fissures, due to their effectiveness and safety profile. This recommendation is based on the most recent and highest quality study 1, which provides strong evidence for the use of calcium channel blockers in the treatment of anal fissures.

From the FDA Drug Label

PATIENT INSTRUCTIONS FOR APPLICATIONS

NOTE: NITRO-BID® can stain clothing

Dosage Instructions: Dosage instructions should be obtained from your physician.

The recommended topical treatment for anal fissures is nitroglycerin ointment. However, the provided drug labels do not directly address the treatment of anal fissures.

• The labels provide instructions for the application of nitroglycerin ointment for angina, not anal fissures.
• There is no mention of the dosage or application instructions for anal fissures.
• Caution should be exercised when using nitroglycerin ointment for off-label purposes, such as treating anal fissures, as the efficacy and safety have not been established in this context 2 2.

From the Research

Topical Treatments for Anal Fissures

• Topical nitroglycerin ointment is a commonly used treatment for anal fissures, with studies showing its effectiveness in healing both acute and chronic fissures 3, 4, 5.
• The application of 0.4% nitroglycerin ointment has been shown to significantly increase the rate of decrease in mean visual-analogue-scale pain scores in patients with chronic anal fissure pain 4.
• However, topical nitroglycerin ointment is often associated with adverse reactions, such as headache, which can be severe in some cases 3, 4, 5.
• Other topical treatments, such as calcium channel blockers (e.g. diltiazem, nifedipine) and botulinum toxin injection, have also been shown to be effective in healing anal fissures, with fewer adverse events than nitroglycerin ointment 6.
• The choice of topical treatment may depend on the severity and persistence of the fissure, as well as the patient's individual response to treatment 7.

Comparison of Topical Treatments

• A systematic review of 75 randomized controlled trials found that nitroglycerin ointment was marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure was common 6.
• The same review found that botulinum toxin injection and calcium channel blockers were equivalent to nitroglycerin ointment in efficacy, with fewer adverse events 6.
• Other topical treatments, such as clove oil and sildenafil, have shown promise in single studies, but require further investigation to determine their effectiveness compared to established medications 6.

Current Guidelines and Recommendations

• Current guidelines recommend the use of topical nitrates, topical calcium channel blockers, or botulinum toxin injection as first-line treatment for anal fissures, with surgical options considered if fissures persist despite treatment 7.
• The choice of treatment should be individualized based on the patient's symptoms, medical history, and response to treatment 7.