How do you write a prescription order for Preparation H (phenylephrine 1% and hydrocortisone 0.5% topical ointment) for an adult with uncomplicated external hemorrhoids?

How to Write a Preparation H Order for Uncomplicated External Hemorrhoids

For an adult with uncomplicated external hemorrhoids, prescribe Preparation H (phenylephrine 0.25% with pramoxine 1%) ointment or cream applied topically to the affected area up to 4 times daily, particularly after bowel movements and at bedtime, for symptomatic relief only—not as definitive treatment.

Critical Context Before Prescribing

• Preparation H provides only symptomatic relief of local pain and itching but lacks strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1
• Over-the-counter topical agents like Preparation H are widely used empirically, but clinical data supporting their long-term effectiveness are lacking 1
• Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks is significantly more effective (92% resolution rate) than standard over-the-counter preparations for external hemorrhoids 1, 2

Prescription Format

Rx: Preparation H Ointment (phenylephrine 0.25% + pramoxine 1%)

• Sig: Apply topically to affected perianal area up to 4 times daily, especially after each bowel movement and at bedtime
• Quantity: 1 tube (30-60 grams)
• Refills: 0-1
• Duration: Use for no more than 7 days 1

Superior Alternative Prescription (Strongly Recommended)

Rx: Nifedipine 0.3% + Lidocaine 1.5% Ointment (compounded)

• Sig: Apply topically to affected area every 12 hours for 2 weeks
• Quantity: 30 grams
• Refills: 0
• Rationale: This combination achieves 92% resolution versus 45.8% with lidocaine alone 1, 2

Mandatory Concurrent Conservative Management

• Prescribe psyllium husk 5-6 teaspoonfuls with 600 mL water daily to soften stool and reduce straining 1
• Instruct increased dietary fiber to 25-30 grams daily and adequate fluid intake 1
• Recommend warm sitz baths 2-3 times daily to reduce inflammation and discomfort 1, 2
• Advise strict avoidance of straining during defecation 1

If Adding Corticosteroid Component

Rx: Hydrocortisone 1% cream (or Preparation H with hydrocortisone)

• Sig: Apply topically to affected area twice daily
• Duration: MAXIMUM 7 days only
• Critical Warning: Prolonged use beyond 7 days causes thinning of perianal and anal mucosa, increasing injury risk 1, 3

When Preparation H Is Inappropriate

• If thrombosed external hemorrhoid presenting within 72 hours: Complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates—not topical therapy 1
• If thrombosed external hemorrhoid presenting after 72 hours: Prescribe nifedipine 0.3% + lidocaine 1.5% ointment instead of Preparation H 1, 2
• If symptoms persist beyond 1-2 weeks: Reassessment is mandatory; do not continue empiric topical therapy 1

Critical Pitfalls to Avoid

• Never use corticosteroid-containing preparations for more than 7 days—this causes perianal tissue thinning 1, 3
• Never attribute significant bleeding or anemia to hemorrhoids without colonoscopic evaluation to exclude proximal colonic pathology 1
• Never assume all anorectal symptoms are hemorrhoids—anal fissures, abscesses, or fistulas may coexist or be the primary cause 1
• Do not perform anoscopy if the patient has acute thrombosed hemorrhoids, as excruciating pain typically requires proper sedation 1

Follow-Up Instructions

• If symptoms worsen or fail to improve within 1-2 weeks, or if significant bleeding, severe pain, or fever develop, further evaluation is necessary 1
• For persistent symptoms despite conservative management, office-based rubber band ligation (70.5-89% success rate) is the preferred next step for internal hemorrhoids 1
• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood requires adequate colonic evaluation 1