What is the treatment for external hemorrhoids?

Treatment of External Hemorrhoids

External hemorrhoids should be managed conservatively with dietary modifications, increased fiber and water intake, and topical treatments as first-line therapy, with surgical excision reserved only for thrombosed external hemorrhoids presenting within 72 hours of symptom onset. 1, 2

Initial Conservative Management (First-Line for All External Hemorrhoids)

All external hemorrhoids should begin with conservative measures regardless of severity 1, 2:

• Increase dietary fiber to 25-30 grams daily and water intake to soften stool and reduce straining during defecation 1
• Avoid straining during bowel movements to prevent exacerbation 1, 2
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1, 2

Pharmacological Treatment for Symptomatic External Hemorrhoids

When conservative measures alone are insufficient, add topical medications 1, 2, 3:

Most Effective Topical Regimen

• Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to only 45.8% with lidocaine alone 1, 2
• Nifedipine works by relaxing internal anal sphincter hypertonicity that contributes to pain, with no systemic side effects reported 1, 2
• Lidocaine provides symptomatic relief of local pain and itching 1, 2, 3

Alternative Topical Options (If Nifedipine/Lidocaine Unavailable)

• Topical lidocaine 5% alone can be applied 3-4 times daily for symptomatic relief, though less effective than the combination 4
• Topical corticosteroid creams may reduce local perianal inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 3
• Topical nitrates show good results for pain relief but are limited by high incidence of headache (up to 50% of patients) 1, 2, 3
• Topical heparin significantly improves healing, though evidence is limited to small studies 1, 2, 3

Oral Medications

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3, 5
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 1

Management of Thrombosed External Hemorrhoids (Time-Dependent Algorithm)

Presentation Within 72 Hours of Symptom Onset

Surgical excision under local anesthesia is recommended as it provides faster pain relief and significantly reduced recurrence rates compared to conservative management 1, 2, 5:

• Complete excision of the thrombosed hemorrhoid can be performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage alone - this leads to persistent bleeding and higher recurrence rates 1, 2

Presentation Beyond 72 Hours of Symptom Onset

Conservative management is preferred as the natural resolution process has already begun 1, 2, 5:

• Use the topical nifedipine/lidocaine combination regimen described above 1, 2
• Add stool softeners and oral analgesics 5
• Topical muscle relaxants can provide additional pain relief, particularly with severe sphincter spasm 1, 2, 3
• Reassess if symptoms worsen or fail to improve within 1-2 weeks 1, 2

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days - prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 2, 3
• Never perform simple incision and drainage of thrombosed external hemorrhoids - this leads to persistent bleeding and higher recurrence rates 1, 2
• Do not apply lidocaine patches to large areas, cut/irritated skin, or for more than one week without consulting a physician 4
• Avoid rubber band ligation for external hemorrhoids in routine practice - external hemorrhoids are covered by anoderm with somatic pain receptors, making this procedure extremely painful without adequate anesthesia 6
• Do not attribute significant bleeding or anemia to external hemorrhoids alone - external hemorrhoids typically cause symptoms only when thrombosed and rarely cause significant bleeding 1

When to Consider Surgical Hemorrhoidectomy

Surgical hemorrhoidectomy for external hemorrhoids is indicated only in specific circumstances 1:

• Mixed internal and external hemorrhoids with symptomatic external component that fails conservative and office-based therapy
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids
• Concomitant anorectal conditions (fissure, fistula) requiring surgery
• Patient preference after thorough discussion of treatment options

Note: Most external hemorrhoids respond to conservative and topical management and do not require surgery 1, 2, 5