What creams are used to treat anal fissures?

Topical Treatments for Anal Fissures

Calcium channel blockers (diltiazem or nifedipine) are the most effective topical treatments for anal fissures, with healing rates of 65-95% and fewer side effects than nitrates. 1

First-Line Topical Treatments

• Calcium channel blockers (CCBs):

  • Diltiazem and nifedipine are the preferred topical treatments for anal fissures 1
  • CCBs block slow L-type calcium channels of vascular smooth muscle cells, reducing internal anal sphincter tone and promoting increased local blood flow 1
  • Associated with healing rates of 65-95%, superior to other non-operative treatments 1
  • Topical application is preferred over oral administration due to fewer systemic side effects 1
  • A specific formulation of 0.3% nifedipine with 1.5% lidocaine has shown 95% healing rate after 6 weeks in a randomized trial 1

• Nitrates (glyceryl trinitrate/nitroglycerin):

  • Act as nitric oxide donors to reduce anal canal pressure and improve anodermal blood flow 2
  • Typically available as 0.2-0.4% ointment 2
  • Less effective than CCBs with healing rates of only 25-50% 3
  • Associated with significant headaches in most patients, which can be severe in 20-25% of cases 2

Pain Management for Anal Fissures

• Topical anesthetics:

  • Lidocaine is the most commonly prescribed topical anesthetic for anal fissures 1
  • Can be combined with other agents (e.g., 0.3% nifedipine with 1.5% lidocaine) for better outcomes 1
  • Helps reduce the reflex spasm of the anal sphincter, enhancing fissure healing 1

• Systemic pain management:

  • Common pain relievers like paracetamol or ibuprofen (oral or parenteral) may be needed for severe pain 1
  • Pain relief typically occurs after approximately 14 days of appropriate treatment 1

Duration of Treatment

• No standard duration is established, but administration for at least 6 weeks is suggested 1, 3
• Pain relief typically occurs after 14 days of treatment 1, 3
• About 50% of acute anal fissures will heal with conservative measures within 10-14 days 1

Treatment Algorithm

1. Start with conservative measures:

   • Stool softeners (increased fluid intake, high-fiber diet, bulk-forming laxatives) 1
   • Warm sitz baths to relax the internal anal sphincter 1, 3
   • Topical anesthetics for pain control 1

2. If inadequate response after 2 weeks, add topical medications:

   • First choice: Calcium channel blockers (diltiazem or nifedipine) 1, 3
   • Alternative: Glyceryl trinitrate ointment if CCBs are unavailable or contraindicated 3, 2

3. Continue treatment for at least 6 weeks 1, 3

4. Consider surgical options only if medical management fails after 8 weeks 3, 4

Important Considerations and Cautions

• Manual dilatation is strongly discouraged due to high risk of incontinence (temporary incontinence rates up to 30% and permanent incontinence up to 10%) 1, 3
• Topical antibiotics may be considered in cases of poor genital hygiene or reduced therapeutic compliance 1
• Atypical fissures (those not in the midline) require evaluation for underlying conditions like Crohn's disease, HIV/AIDS, ulcerative colitis, or cancer 3
• Signs of chronicity include sentinel tag, hypertrophied papilla, and fibrosis 3