How to Apply Diltiazem 2% Cream for Anal Fissure
Apply approximately 2 cm (equivalent to 8 mg) of diltiazem 2% cream directly to the anal verge twice daily for at least 8 weeks. 1
Application Technique
Apply the cream topically to the distal anal canal and anal verge using a clean finger or applicator, ensuring direct contact with the fissure site. 2, 3
Use approximately 2 cm of gel (equivalent to 8 mg of diltiazem hydrochloride) per application—this is the standardized dose that has been validated in clinical studies. 2
Apply twice daily (morning and evening) consistently throughout the treatment course. 1, 4, 2
Treatment Duration and Expectations
Continue treatment for a minimum of 8 weeks, as healing rates improve with extended therapy—48-75% of chronic anal fissures heal within this timeframe. 1, 5
Pain relief typically begins within the first 1-2 weeks, though complete fissure healing requires the full 8-week course. 6, 7
If the fissure has not healed after 8 weeks, consider extending treatment for an additional 8 weeks, as some patients require up to 16 weeks for complete healing. 5
Essential Adjunctive Measures
Increase dietary fiber to 25-30g daily and ensure adequate water intake to soften stools and minimize anal trauma during defecation. 8, 9
Take warm sitz baths multiple times daily to promote sphincter relaxation and reduce pain. 8, 9
Use oral analgesics (acetaminophen or ibuprofen) for breakthrough pain, especially around bowel movements. 9
Mechanism of Action
Diltiazem blocks L-type calcium channels in vascular smooth muscle, reducing internal anal sphincter tone by approximately 20% and increasing local blood flow to the ischemic ulcer. 6, 3
The reduction in sphincter pressure breaks the pain-spasm-ischemia cycle that perpetuates the fissure. 8
Side Effects and Compliance
Perianal itching or dermatitis occurs in approximately 10% of patients but rarely requires discontinuation of therapy. 3, 5
Severe perianal exanthema developed in 10.3% of patients in one study, which may necessitate switching to alternative therapy. 7
Headaches are rare with diltiazem (unlike nitroglycerin, which causes headaches in many patients), making it better tolerated. 3, 5
Critical Pitfalls to Avoid
Never perform manual anal dilatation, as this is absolutely contraindicated due to unacceptably high permanent incontinence rates of 10-30%. 8, 9
Do not discontinue fiber and water intake after healing, as this is the primary cause of recurrence. 9
Be aware that 59% of patients may require further treatment (medical and/or surgical) over a 2-year follow-up period, so close monitoring is essential. 4
When to Consider Alternative Treatment
If the fissure fails to heal after 8-16 weeks of diltiazem therapy, consider botulinum toxin injection (75-95% cure rates) or lateral internal sphincterotomy (>95% healing rates). 1
Diltiazem is effective in 44-75% of patients who previously failed glyceryl trinitrate treatment, making it an excellent second-line option. 3