What is the best ointment for hemorrhoids?

Best Ointment for Hemorrhoids

Low-potency topical corticosteroids (hydrocortisone 1%) applied 3-4 times daily for a maximum of 7 days is the best initial ointment treatment for hemorrhoids, as recommended by the World Health Organization and the American Gastroenterological Association. 1

Treatment Algorithm for Hemorrhoidal Disease

First-Line Conservative Management

1. Dietary and Lifestyle Modifications

   • Increase fiber intake (25-30g daily)
   • Ensure adequate hydration
   • Sitz baths 2-3 times daily
   • Regular physical activity
   • Avoid straining and prolonged sitting 1, 2

2. Topical Treatments

   • Hydrocortisone 1% ointment (3-4 times daily for maximum 7 days)
     • Reduces perianal skin irritation and inflammation
     • Caution: Prolonged use can cause skin atrophy 1
   • Phlebotonics (flavonoids) to improve venous tone
     • Reduces bleeding, pain, and swelling
     • Note: 80% symptom recurrence within 3-6 months after stopping 2

Second-Line Management (For Persistent Symptoms)

1. Office-Based Procedures (for grade I-III internal hemorrhoids)

   • Rubber band ligation (89% success rate)
   • Sclerotherapy (70-85% short-term efficacy)
   • Infrared coagulation (70-80% success in reducing bleeding and prolapse) 1, 2

2. Surgical Management (for grade III-IV or treatment-resistant hemorrhoids)

   • Excisional hemorrhoidectomy (gold standard for grade IV)
   • Stapled hemorrhoidopexy (less postoperative pain but higher recurrence)
   • Hemorrhoidal artery ligation (for grade II-III) 1

Special Considerations for Topical Treatments

Emerging Treatments

Sucralfate-based topical products have shown promise as a mechanical barrier to facilitate healing. In a recent 2024 study, both ointment and suppository forms significantly improved patient-assessed symptoms with high satisfaction rates (81.3%) and excellent tolerability 3.

Treatment Based on Hemorrhoid Classification

• First and Second Degree: Topical treatments are most effective
• Third and Fourth Degree: May require procedural or surgical intervention in addition to topical treatments 1, 2

External Thrombosed Hemorrhoids

• Outpatient clot evacuation within 72 hours of onset
• If presenting >72 hours: stool softeners, oral and topical analgesics (5% lidocaine) 2

Pitfalls and Caveats

1. Duration of Corticosteroid Use

   • Limit corticosteroid ointments to 7 days maximum
   • Prolonged use can lead to skin atrophy and other complications 1

2. Special Patient Populations

   • Immunocompromised patients: Higher infection risk with procedures
   • Cirrhosis/portal hypertension: Distinguish from rectal varices
   • Pregnancy: Conservative management preferred
   • Inflammatory bowel disease: Caution with surgical interventions 1

3. When to Refer for Specialist Care

   • Persistent bleeding despite conservative treatment
   • Grade III-IV hemorrhoids
   • Failed office-based procedures
   • Uncertain diagnosis 1, 2

The evidence strongly supports hydrocortisone 1% as the most effective ointment for initial treatment of hemorrhoids, with the important caveat that it should be limited to 7 days of use. For long-term management, dietary and lifestyle modifications remain the cornerstone of therapy, with procedural interventions reserved for persistent or advanced cases 1, 2.