What are the best topical treatments for anal fissures?

Best Topical Treatments for Anal Fissures

Topical calcium channel blockers (diltiazem or nifedipine) are the best first-line topical treatment for anal fissures that fail conservative management, offering healing rates of 65-95% with minimal side effects and superior tolerability compared to glyceryl trinitrate. 1

Treatment Algorithm

Step 1: Conservative Management (First 2 Weeks)

Start all patients with conservative measures before considering topical medications 1:

• Fiber supplementation and adequate fluid intake to soften stools 1
• Warm sitz baths to relax the internal anal sphincter 1
• Topical lidocaine for pain control (apply 3-4 times daily maximum) 1, 2
• Approximately 50% of anal fissures heal with conservative care alone within this timeframe 1

Step 2: Add Topical Calcium Channel Blockers (If No Improvement After 2 Weeks)

Topical diltiazem or nifedipine should be your first-choice topical medication 1:

• Healing rates: 65-95% 1
• Significantly fewer side effects compared to glyceryl trinitrate 1
• Apply twice daily to the lower anal canal 1

Step 3: Alternative Topical Options

Glyceryl trinitrate (GTN) 0.2% ointment is a second-line topical option 1:

• Healing rates: 25-50% (lower than calcium channel blockers) 1, 3, 4
• Major limitation: headaches are a common side effect, causing treatment discontinuation in many patients 5, 3
• Apply twice daily for 6-8 weeks 3, 4
• Works by causing reversible chemical sphincterotomy and increasing anodermal blood flow 3

Step 4: Botulinum Toxin Injection (If Topical Treatments Fail)

If topical treatments fail after 8 weeks, consider botulinum toxin injection before surgery 1:

• Cure rates: 75-95% with low morbidity 1
• Superior to nitroglycerin in head-to-head comparison (96% vs 60% healing) 5
• Causes temporary sphincter relaxation 1

Pain Management Strategy

Pain control is essential because it reduces reflex spasm of the anal sphincter, which enhances healing 1, 6:

• Topical lidocaine is the most commonly prescribed topical anesthetic 1
• Apply to affected area not more than 3-4 times daily 2
• Wash hands with soap and water after application 2
• Pain relief typically occurs within 14 days of starting appropriate treatment 6

Critical Cautions

Avoid these interventions 1:

• Manual dilatation: High risk of temporary and permanent incontinence 1, 6
• Surgical treatment for acute fissures: Should only be considered after 8 weeks of failed non-operative management 1, 6

Special Considerations

For cases with poor genital hygiene, consider adding metronidazole to traditional therapies 1:

• One study showed improved healing rates (86% vs 56%) when metronidazole was added to lidocaine 1
• Evidence is limited and recommendation is weak 1

Red Flags Requiring Further Evaluation

Atypical fissure locations (not in the posterior midline) require evaluation for underlying conditions 6:

• Consider Crohn's disease or inflammatory bowel disease 6
• Signs of chronicity include sentinel tag, hypertrophied papilla, fibrosis, and visualization of bare internal sphincter muscle 6

Evidence Quality Note

The recommendation for calcium channel blockers over GTN is based on American College of Gastroenterology guidelines 1, which supersedes older research studies showing GTN efficacy 5, 3, 4. While GTN does work (healing rates 60-68% in controlled trials 5, 3), the side effect profile makes calcium channel blockers the superior choice in clinical practice 1.