Can prolonged use of hydrocortisone (corticosteroid) cream on the anus cause chronic anal fissures in an adult patient?

Hydrocortisone Does Not Cause Chronic Anal Fissures, But Prolonged Use Can Worsen Them

Prolonged use of hydrocortisone cream on the anus does not directly cause chronic anal fissures, but it can significantly worsen existing fissures and impair healing by causing perianal skin thinning and atrophy, making the tissue more vulnerable to injury. 1

Critical Time Limit for Hydrocortisone Use

• Hydrocortisone should be limited to a maximum of 7 days of use due to the risk of perianal skin thinning and atrophy. 1
• The FDA label explicitly warns against prolonged use and states that treatment should not exceed 7 days unless directed by a physician. 2
• Using hydrocortisone beyond 7 days increases the risk of skin atrophy and makes the perianal tissue more susceptible to injury and fissure formation. 1

Mechanism of Harm with Prolonged Use

• Chronic corticosteroid application causes progressive thinning of the perianal skin, which reduces the tissue's ability to withstand normal mechanical stress during defecation. 1
• This skin atrophy creates a vicious cycle where the weakened tissue is more prone to tearing, potentially converting acute fissures into chronic ones or preventing existing fissures from healing. 1
• The compromised skin integrity from prolonged steroid use can perpetuate the pain-spasm-ischemia cycle that characterizes chronic anal fissures. 1

What Actually Causes Chronic Anal Fissures

• Chronic anal fissures develop from persistent hypertonia and spasm of the internal anal sphincter, creating an ischemic ulcer that fails to heal. 3
• Approximately 50% of acute anal fissures heal within 10-14 days with conservative management alone. 1, 4
• Fissures that persist beyond 2 weeks despite conservative treatment may progress to chronicity. 5

Appropriate Treatment Approach

• First-line treatment should consist of dietary modifications (25-30g fiber daily), adequate fluid intake, and stool softeners—not hydrocortisone. 1
• If fissures persist beyond 2 weeks, calcium channel blockers (0.3% nifedipine with 1.5% lidocaine) are the preferred topical therapy, with healing rates of 65-95%. 1, 5
• Topical nifedipine should be applied three times daily for at least 6 weeks, with pain relief typically occurring after 14 days. 1

Critical Clinical Pitfall

• The most common mistake is using hydrocortisone as a treatment for anal fissures when it should be strictly avoided or limited to 7 days maximum. 1, 2
• Hydrocortisone does not address the underlying pathophysiology of anal fissures (sphincter hypertonia and ischemia) and may actually impede healing through tissue weakening. 1