Can Anusol (hydrocortisone) cause or worsen anal fissures?

Anusol Does Not Cause Anal Fissures, But Prolonged Use May Worsen Healing

Anusol (hydrocortisone) does not cause anal fissures, but should be limited to a maximum of 7 days of use due to the risk of perianal skin thinning and atrophy, which could theoretically impair healing and increase vulnerability to injury. 1

Understanding the Relationship Between Topical Steroids and Anal Fissures

What Actually Causes Anal Fissures

Anal fissures are longitudinal tears in the anal canal extending from the dentate line to the anal verge, with a multifactorial etiology that includes:

• Mechanical trauma from passage of hard stools (though less than 25% of patients with fissures complain of constipation) 2
• Internal anal sphincter hypertonia with decreased anodermal vascular blood flow, supporting the ischemic ulcer theory 2
• Sphincter spasm creating a pain-spasm-ischemia cycle that perpetuates the condition 1, 3

The Risk of Hydrocortisone in Anal Fissure Management

The critical concern with Anusol (hydrocortisone) is not that it causes fissures, but that prolonged use beyond 7 days leads to perianal skin atrophy and thinning, which increases the risk of skin injury and impairs healing. 1

• Hydrocortisone should be strictly limited to 7 days maximum to avoid these complications 1
• Skin thinning from prolonged steroid use could theoretically make the perianal area more susceptible to new tears or prevent existing fissures from healing 1

Evidence-Based First-Line Treatment for Anal Fissures

If you have an anal fissure, non-operative management is the mandatory first-line treatment, with approximately 50% healing within 10-14 days using conservative measures alone. 2, 3

The Correct Treatment Algorithm

Dietary and lifestyle modifications (strong recommendation):

• High-fiber diet of 25-30g daily or fiber supplementation to soften stools 1
• Increased oral fluid intake to prevent constipation 2, 3
• Warm sitz baths multiple times daily to promote sphincter relaxation 2, 3

Topical pharmacologic therapy (when conservative measures alone are insufficient):

• Compounded 0.3% nifedipine with 1.5% lidocaine cream applied three times daily for at least 6 weeks achieves 95% healing rates 1, 3
• Nifedipine blocks L-type calcium channels in vascular smooth muscle, reducing internal anal sphincter tone and increasing local blood flow to the ischemic ulcer 1, 3
• Lidocaine provides local anesthesia, breaking the pain-spasm-ischemia cycle 1, 3
• Pain relief typically occurs after 14 days, with full healing by 6 weeks 1

Pain control strategy:

• Topical lidocaine (included in the compounded cream) for continuous local anesthesia 3
• Oral analgesics (paracetamol or ibuprofen) for breakthrough pain around bowel movements 3

Critical Pitfalls to Avoid

• Never perform manual anal dilatation - this is strongly contraindicated due to high risk of permanent incontinence (up to 10%) and temporary incontinence (up to 30%) 2, 3, 4
• Do not use hydrocortisone beyond 7 days due to risk of skin atrophy and increased injury 1
• Do not stop fiber and water intake after healing, as this is the primary cause of recurrence 3

When to Consider Surgery

If symptoms persist after 8 weeks of optimal non-operative management, the fissure is classified as chronic and surgical options should be considered. 2, 1, 3 Lateral internal sphincterotomy remains the gold standard with the highest long-term efficacy, though it carries some risk of incontinence. 4, 5, 6