What are the topical treatments for anal fissure?

From the Guidelines

For anal fissures, the recommended topical treatment is diltiazem 2% ointment applied 3 times daily for 6-8 weeks, due to its high healing rate and low risk of side effects, as shown in a recent systematic review and meta-analysis 1. The goal of topical therapy is to reversibly decrease resting anal pressure, allowing the fissure to heal without permanent sphincter damage.

• Diltiazem 2% ointment is a calcium channel blocker that relaxes the internal anal sphincter, improving blood flow to the area and promoting healing.
• Before application, the area should be cleaned gently with warm water and patted dry.
• A pea-sized amount of ointment should be applied using a gloved finger or cotton swab.
• Alongside medication, patients should maintain soft stools through adequate fluid intake (6-8 glasses of water daily), fiber supplementation (25-30g daily), and warm sitz baths for 10-15 minutes 2-3 times daily to relieve pain and promote healing.
• If symptoms don't improve after 8 weeks or worsen at any point, further medical evaluation is necessary as surgical options may be required.
• Nitroglycerin ointment is also an option, but it has a higher risk of side effects, such as headaches, compared to diltiazem 1.
• Nifedipine 0.2-0.5% ointment is another alternative, but diltiazem is preferred due to its higher healing rate and lower risk of side effects, as shown in a recent study 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 fissure is not explicitly mentioned in the provided drug labels. However, based on the available information, lidocaine (TOP) can be applied to the affected area.

• It is for external use only.
• It should not be used on cut, irritated or swollen skin.
• It can be applied not more than 3 to 4 times daily 2. However, the provided drug labels do not directly support the use of lidocaine (TOP) for fissure treatment.

From the Research

Topical Treatment Options for Anal Fissure

• Various topical treatments have been explored for the management of anal fissure, including glyceryl trinitrate (GTN) ointment, diltiazem ointment, botulinum toxin injections, and nitroglycerin ointment 3, 4, 5, 6, 7
• These treatments aim to reduce anal tone and sphincter spasm, promoting ulcer healing and avoiding the need for surgical sphincterotomy, which can lead to fecal incontinence 3, 4

Efficacy of Topical Treatments

• GTN ointment has been shown to have an efficacy of up to 68% in healing chronic anal fissure, although it is associated with headaches as a common side effect 3, 6
• Diltiazem ointment has achieved healing rates comparable to GTN ointment, with fewer side effects 3, 6
• Botulinum toxin injections have been found to be highly effective, with healing rates of over 80% in some studies, although they are more invasive and expensive than GTN therapy 3, 4, 7
• Nitroglycerin ointment has also been used, with studies suggesting that controlled intra-anal dosing can reduce sphincteric pressure and minimize side effects such as headaches 5

Comparison of Topical Treatments

• A systematic review and meta-analysis found that GTN was significantly more likely to heal anal fissure than placebo, with a relative risk of 1.96 6
• The same review found that diltiazem was not significantly more effective than placebo, although it had a marginally significant difference in healing rates compared to GTN 6
• A retrospective study found that the combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation in terms of healing and recurrence rates 7