What is the recommended topical treatment for an otherwise healthy adult patient with an anal fissure?

Topical Treatment for Anal Fissure

First-Line Recommendation

For an otherwise healthy adult with an anal fissure, apply compounded 2% diltiazem cream to the anal verge twice daily for 8 weeks, combined with fiber supplementation (25-30g daily), adequate hydration, warm sitz baths, and topical lidocaine 5% for pain control. 1

Treatment Algorithm

Step 1: Conservative Management (All Patients, First 2 Weeks)

• Fiber supplementation: 25-30g daily to soften stools and minimize anal trauma 1
• Adequate fluid intake: Prevents constipation 1
• Warm sitz baths: Promote sphincter relaxation and local blood flow 1
• Topical lidocaine 5%: For pain control 1

Approximately 50% of acute anal fissures heal with this conservative approach alone within 10-14 days. 1

Step 2: Pharmacologic Therapy (If No Improvement After 2 Weeks)

Primary option: Compounded 2% diltiazem cream applied twice daily for 8 weeks achieves healing rates of 48-75% with minimal side effects. 1 This is preferred over other topical agents due to superior tolerability.

Alternative options if diltiazem unavailable:

• Compounded 0.3% nifedipine with 1.5% lidocaine applied three times daily achieves 95% healing after 6 weeks by reducing internal anal sphincter tone and increasing local blood flow 1
• Topical nitroglycerin (GTN): Shows only 25-50% healing rates and causes headaches in many patients, making it a less preferred option 1, 2, 3

Step 3: Second-Line Interventions (If Failure After 8 Weeks of Topical Therapy)

• Botulinum toxin injection into the internal anal sphincter demonstrates 75-95% cure rates with low morbidity 1, 4
• 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

Evidence Comparison and Nuances

The guideline evidence strongly favors diltiazem over GTN based on comparable efficacy (48-75% vs 25-50%) with superior side effect profile. 1, 3 While one older RCT 2 from 2005 showed comparable healing between GTN and sphincterotomy at 6 weeks, the guideline evidence from 2026 1 emphasizes that medical therapies remain far less effective than surgery for chronic fissures, with LIS achieving >95% healing versus 48-75% for topical agents.

The compounded nifedipine-lidocaine combination shows the highest healing rate (95%) among topical agents 1, making it an excellent alternative to diltiazem when available.

Critical Pitfalls to Avoid

• Never use hydrocortisone beyond 7 days: Risk of perianal skin thinning and atrophy that worsens the fissure 1
• Avoid coconut oil: Provides only superficial lubrication with no pharmacologic action to reduce sphincter tone or increase blood flow 1
• Never perform manual anal dilatation: Unacceptably high permanent incontinence rates of 10-30% 1
• Do not rush to surgery for acute fissures: 50% heal with conservative management alone 1

Red Flags Requiring Further Evaluation

• Off-midline fissure location: Urgently evaluate for Crohn's disease, IBD, HIV, syphilis, herpes, anorectal cancer, or tuberculosis 1
• Failure to respond after 8 weeks: Reassess for atypical pathology 1
• Multiple fissures or atypical appearance: Consider endoscopy, CT, MRI, or endoanal ultrasound 5

Special Consideration: Anal Atony

If the patient has low anal sphincter pressures (anal atony), avoid all sphincter-relaxing agents (diltiazem, nifedipine, GTN, botulinum toxin) and focus exclusively on conservative management with fiber, hydration, sitz baths, and topical anesthetics only. 5 These patients require investigation for neurologic disease, prior sphincter injury, or IBD. 5