From the Guidelines
Topical calcium channel blockers, such as diltiazem (2%) or nifedipine (0.2-0.5%), are the most effective treatment for anal fissures, with healing rates ranging from 65 to 95% and fewer side effects compared to nitroglycerin ointment 1. The primary goal of treating anal fissures is to achieve internal anal sphincter (IAS) relaxation, reduce pain, and facilitate the healing process. Topical treatments, including calcium channel blockers and nitroglycerin ointment, work by relaxing the IAS, improving blood flow to the area, and promoting healing.
- Conservative measures, such as increased fiber intake (25-30g daily), adequate hydration (8 glasses of water daily), sitz baths (10-15 minutes in warm water 2-3 times daily), and stool softeners like docusate sodium, should accompany topical treatment.
- Patients should avoid straining during bowel movements and maintain good anal hygiene.
- If symptoms persist beyond 8 weeks of treatment or if pain is severe, surgical consultation may be necessary.
- According to a recent systematic review and meta-analysis, calcium channel blockers are more effective than glyceryl trinitrate and have fewer side effects, such as headache and hypotension 1.
- The use of botulinum toxin injections is not recommended due to limited evidence and potential side effects 1.
- Topical anesthetics and common pain killers may be used for pain control in patients with acute anal fissure, but their effectiveness is based on low-quality evidence 1.
From the FDA Drug Label
Directions Adults and children over 12 years: ◆ Apply to affected area not more than 3 to 4 times daily Warnings For external use only Do not use ◆ on large areas of the body or on cut, irritated or swollen skin The topical treatment for anal fissure using lidocaine (TOP) is to apply to the affected area not more than 3 to 4 times daily 2. However, it is crucial to note that the drug label warns against using the product on cut, irritated or swollen skin 2, which may be a concern for anal fissures. Therefore, it is recommended to use only as directed and consult a doctor if the condition worsens or if symptoms persist for more than 7 days 2. Key considerations include:
- Applying the product to the affected area not more than 3 to 4 times daily
- Avoiding use on cut, irritated or swollen skin
- Consulting a doctor if the condition worsens or if symptoms persist for more than 7 days
From the Research
Topical Treatment for Anal Fissure
- Topical nitrates, such as nitroglycerin, have been shown to cause nitric oxide-mediated relaxation of the internal anal sphincter, which can help in the treatment of anal fissures 3, 4, 5.
- Studies have reported varying success rates for topical nitroglycerin in treating anal fissures, with healing rates ranging from 41% to 75% for chronic fissures and 56% to 83% for acute fissures 3, 4.
- However, topical nitroglycerin is often associated with adverse reactions, such as headaches, which can occur in up to 77% of patients 3, 4, 5.
- Alternative topical treatments, such as diltiazem, have been shown to be effective in treating chronic anal fissures, with healing rates comparable to nitroglycerin but with fewer side effects 6, 7.
- Diltiazem has been used as a second-line treatment for patients who have failed glyceryl trinitrate therapy, with a healing rate of 48% and symptomatic improvement in an additional 22% of patients 7.
- Other topical treatments, such as lidocaine, indoramin, and minoxidil, have also been explored, but their efficacy and safety profiles are less well established 6.