Which cream can be applied inside the anal canal for an anal fissure?

Topical Nifedipine-Lidocaine Cream for Internal Anal Canal Application

For internal anal canal application in anal fissures, use compounded 0.3% nifedipine with 1.5% lidocaine cream applied three times daily for at least 6 weeks, which achieves a 95% healing rate. 1

Recommended Formulation and Application

• The evidence-based formulation is 0.3% nifedipine combined with 1.5% lidocaine, applied directly to the anal verge and can be applied inside the anal canal three times daily. 1
• Treatment must continue for a minimum of 6 weeks, with pain relief typically beginning after 14 days of consistent use. 1, 2
• This combination works through dual mechanisms: nifedipine blocks L-type calcium channels in the internal anal sphincter to reduce tone and increase blood flow to the ischemic fissure, while lidocaine provides immediate local anesthesia to break the pain-spasm-ischemia cycle. 1, 2

Alternative Calcium Channel Blocker Option

• If nifedipine is unavailable, compounded 2% diltiazem cream applied twice daily for 8 weeks is an acceptable alternative, though it demonstrates lower healing rates of 48-75% compared to nifedipine's 95%. 3
• Diltiazem has the advantage of fewer side effects, particularly avoiding the headaches commonly seen with nitroglycerin (GTN). 3
• Recent comparative research shows nifedipine achieves 77.4% remission versus diltiazem's 54% remission at 8 weeks, with faster pain relief in the nifedipine group. 4

Essential Adjunctive Measures

• All patients must increase fiber intake to 25-30g daily through diet or supplementation to soften stools and prevent anal trauma during defecation. 3, 2
• Adequate fluid intake throughout the day is mandatory to prevent constipation. 3, 2
• Warm sitz baths 2-3 times daily promote internal anal sphincter relaxation and should be used alongside topical therapy. 3, 2

Critical Pitfalls to Avoid

• Never use hydrocortisone cream beyond 7 days, as it causes perianal skin thinning and atrophy that worsens the fissure. 1, 2
• Manual anal dilatation is absolutely contraindicated due to permanent incontinence rates of 10-30%. 3, 2
• Do not rush to surgery for acute fissures, as approximately 50% heal with conservative management alone within 10-14 days. 3, 2

When to Escalate Treatment

• If symptoms persist after 8 weeks of topical calcium channel blocker therapy, the fissure is classified as chronic and requires escalation. 1
• Second-line options include botulinum toxin injection (75-95% cure rates) or referral for lateral internal sphincterotomy, which remains the gold standard with >95% healing rates. 3
• Lateral internal sphincterotomy should only be considered after documented failure of 6-8 weeks of comprehensive medical management. 3, 2

Important Clinical Context

• Topical calcium channel blockers demonstrate remarkable cost-effectiveness compared to surgical interventions while maintaining high healing rates. 1
• For patients who previously failed GTN therapy due to headaches or poor efficacy, diltiazem offers a 48-49% healing rate as salvage therapy. 5, 6
• The combination of nifedipine with lidocaine is superior to diltiazem alone based on the most recent comparative data showing significantly higher remission rates and faster symptom relief. 4