What is the best topical treatment for external hemorrhoids?

Best Topical Treatment for External Hemorrhoids

For external hemorrhoids, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours is the most effective topical treatment, with a 92% resolution rate of acute thrombosed external hemorrhoids after 14 days of therapy. 1

Understanding External Hemorrhoids

• External hemorrhoids originate below the dentate line and typically cause symptoms only when thrombosed, resulting in acute pain 2
• Thrombosed external hemorrhoids present with acute-onset anal pain and a palpable perianal lump 3
• External hemorrhoids occasionally bleed when local pressure causes erosion through the overlying skin 3

First-Line Conservative Management

• Conservative management with dietary and lifestyle modifications should be implemented for all hemorrhoid grades 2
• Increase fiber and water intake to soften stool and reduce straining 2
• Avoid straining during defecation to prevent exacerbation of symptoms 3

Topical Treatment Options

Calcium Channel Blockers (First Choice)

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective 3
• This combination provides complete pain relief in 86% of patients after 7 days of therapy 1
• Significantly reduces the need for oral analgesics compared to lidocaine alone (8% vs 54.1%) 1
• Achieves 92% resolution rate of acute thrombosed external hemorrhoids after 14 days 1
• Works by relaxing internal anal sphincter hypertonicity which contributes to pain 3
• No systemic side effects have been observed with topical nifedipine application 3

Topical Anesthetics

• Lidocaine provides symptomatic relief of local pain and itching 3
• Should be applied to affected area no more than 3-4 times daily 4
• Should not be used on large areas of the body or on cut, irritated, or swollen skin 4
• Do not use for more than one week without consulting a doctor 4
• Avoid bandaging or applying local heat to the area 4

Corticosteroid Creams

• May ameliorate local perianal inflammation 3
• Should be applied for no more than 7 days 3
• Long-term use should be avoided due to potential thinning of perianal and anal mucosa, increasing risk of injury 3
• No data suggest they actually reduce hemorrhoidal swelling, bleeding, or protrusion 3

Topical Nitrates

• Topical nitrates have shown good results in relieving pain due to thrombosed external hemorrhoids 3
• Work by decreasing anal tone 3
• High incidence of headache may limit their use 3

Topical Anti-thrombotics

• Topical heparin treatment has been found to significantly improve healing and resolution of acute hemorrhoids 3
• Limited evidence due to small number of patients in studies 3

Management of Thrombosed External Hemorrhoids

Early Presentation (within 72 hours)

• Excision under local anesthesia provides faster pain relief and reduces risk of recurrence 2

Later Presentation (>72 hours)

• Conservative management with topical treatments is preferred 2
• Topical nifedipine with lidocaine is the most effective option 1
• Stool softeners and oral analgesics may be added as needed 5

Important Considerations

• Symptoms requiring medical attention include worsening condition, persistent redness, irritation development, or symptoms persisting for more than 7 days 4
• Discontinue use and consult a doctor if you experience signs of skin injury such as pain, swelling, or blistering where the product was applied 4
• After applying topical treatments, wash hands with soap and water 4
• Keep all topical treatments out of reach of children 4