What are the recommended ointments or creams for a patient with hemorrhoids?

Recommended Ointments for Hemorrhoids

The most effective topical treatment is 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks, achieving 92% resolution compared to 45.8% with lidocaine alone. 1

First-Line Topical Therapy

Nifedipine + Lidocaine Combination (Most Effective)

• Apply 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1
• Works by relaxing internal anal sphincter hypertonicity which contributes to pain 1
• No systemic side effects have been observed with topical nifedipine application 1
• Particularly effective for thrombosed external hemorrhoids 1
• Superior to all other topical options with documented 92% resolution rate 1, 2

Lidocaine Alone (Symptomatic Relief)

• Use 1.5-2% lidocaine ointment or cream for pain and itching relief 1
• Can apply 5% lidocaine gel or patches for up to 12-24 hours 1
• Apply to affected area not more than 3 to 4 times daily 3
• Provides symptomatic relief but does not address underlying pathology 1
• Minimal systemic absorption even with repeated anorectal administration 1, 2

Short-Term Adjunctive Topical Therapy

Corticosteroid Creams (Maximum 7 Days Only)

• Apply for NO MORE than 7 days to avoid thinning of perianal and anal mucosa 1, 4, 2
• May ameliorate local perianal inflammation 1
• Hydrocortisone foam can be used safely in third trimester pregnancy 1
• Never use long-term—prolonged use causes perianal tissue thinning and increased injury risk 1, 4, 2

Alternative Topical Options (Less Preferred)

Topical Nitrates

• Show good results for thrombosed hemorrhoids 1
• Major limitation: high incidence of headache may limit use 1, 2
• Less preferred than nifedipine/lidocaine combination due to side effects 1

Topical Heparin

• Significantly improves healing and resolution of acute hemorrhoids 1
• Limited evidence available due to small number of patients in studies 1

Over-the-Counter Preparations

Important Limitations

• Suppository medications and over-the-counter topical agents provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1
• Clinical data supporting effectiveness of most OTC products are lacking 1
• Topical analgesics can provide symptomatic relief of local pain and itching, though data supporting long-term efficacy are limited 1

Essential Concurrent Measures

Dietary and Lifestyle Modifications (Always Required)

• Increase fiber to 25-30 grams daily and water intake to soften stool and reduce straining—this is first-line therapy for all hemorrhoid grades 1, 4, 2
• Psyllium husk 5-6 teaspoonfuls with 600 mL water daily 1, 2
• Avoid straining during defecation 1
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Systemic Therapy

• Flavonoids relieve bleeding, pain, and swelling through improvement of venous tone 1, 4, 2
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 1, 2

Critical Safety Warnings

Application Guidelines for Lidocaine Products

• For external use only 3
• Do not use on large areas of the body or on cut, irritated or swollen skin 3
• After applying, wash hands with soap and water 3
• Avoid contact with eyes and mucous membranes 3
• A transient burning sensation may occur upon application but generally disappears in several days 3

When to Discontinue and Seek Medical Attention

• Discontinue use if condition worsens, redness is present, irritation develops, or symptoms persist for more than 7 days 3
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1

Special Populations

Pregnancy and Postpartum

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Hydrocortisone foam can be used safely in third trimester 1
• Tribenoside + lidocaine combination (5%/2% cream or 400mg/40mg suppository) can be safely administered in postpartum women and pregnant women after first trimester 5

Common 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, 4, 2
• Do not rely solely on topical preparations without addressing underlying dietary and lifestyle factors 1, 4
• Avoid assuming all anorectal symptoms are due to hemorrhoids—other conditions like anal fissures, abscesses, or fistulas may coexist 1
• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until colon is adequately evaluated 1, 2