What cream is recommended for treating an anal fissure?

Recommended Cream for Anal Fissure

For anal fissure treatment, use compounded 2% diltiazem cream applied to the anal verge twice daily for 8 weeks as first-line pharmacologic therapy, achieving healing rates of 48-75% without significant side effects. 1, 2

First-Line Conservative Management (Before Any Cream)

Start all patients with conservative measures for 10-14 days, as approximately 50% of acute anal fissures heal with this approach alone: 1, 2

• Fiber supplementation: 25-30g daily to soften stools and minimize anal trauma 1, 2
• Adequate fluid intake to prevent constipation 1
• Warm sitz baths to promote sphincter relaxation 1, 2
• Topical analgesics (lidocaine 5%) for pain control 1, 3

Pharmacologic Cream Options (When Conservative Management Fails After 2 Weeks)

Primary Recommendation: Diltiazem 2%

• Apply 2 cm (approximately 0.7g) of 2% diltiazem cream to the anal verge twice daily for 8 weeks 1, 2
• Healing rates: 48-75% 1, 2, 4, 5
• Pain relief typically occurs within 14 days 2, 3
• Minimal side effects (occasional perianal dermatitis in <6% of patients) 5
• Superior to nitroglycerin in both efficacy and tolerability 1

Alternative Option: Nifedipine/Lidocaine Combination

• Compounded 0.3% nifedipine with 1.5% lidocaine applied three times daily achieves 95% healing after 6 weeks 1
• Mechanism: reduces internal anal sphincter tone and increases local blood flow 1
• Consider this when diltiazem is unavailable or ineffective 1

Less Preferred Option: Nitroglycerin (GTN)

• Topical nitroglycerin 0.2-0.3% applied three times daily 6
• Lower healing rates: 25-50% 1, 2
• Major limitation: causes headaches in 75% of patients, leading to poor compliance 1, 6
• Only marginally better than placebo (48.9% vs 35.5%) 7

Critical Pitfalls to Avoid

• Never use hydrocortisone beyond 7 days due to risk of perianal skin thinning and atrophy, which worsens the fissure 1
• Coconut oil is ineffective as it provides only superficial lubrication without pharmacologic action to reduce sphincter tone or increase blood flow 1
• Manual anal dilatation is absolutely contraindicated due to 10-30% permanent incontinence rates 1, 2, 3

When to Escalate Treatment

After 8 Weeks of Failed Diltiazem Therapy:

1. Botulinum toxin injection: 75-95% cure rates with low morbidity 1, 2
2. Lateral internal sphincterotomy (LIS): Gold standard for chronic fissures with >95% healing rates and 1-3% recurrence, though carries small risk of minor permanent incontinence 1, 2

Red Flags Requiring Urgent Evaluation:

• Fissure located off the posterior midline (suggests Crohn's disease, inflammatory bowel disease, tuberculosis, syphilis, or cancer) 1, 2, 3
• No response to conservative treatment after 8 weeks 1, 3
• Signs of chronicity: sentinel tag, hypertrophied papilla, fibrosis, visualization of bare internal sphincter muscle 2, 3

Pediatric Considerations

For children, the same conservative management and diltiazem approach applies, but surgical interventions should be avoided in acute fissures and reserved only for chronic fissures non-responsive after 8 weeks of conservative management. 3