What is diltiazem 2% cream and how does it work?
Diltiazem, like nifedipine, is a calcium channel blocker, a drug family used for decades as tablets for blood pressure and heart rhythm. For a fissure, it is mixed into a cream or ointment at 2 % and applied to the anal canal, where it relaxes the internal sphincter.
Why that matters: a chronic fissure is a tear that stays open because the muscle underneath is in constant spasm. The spasm raises the resting pressure of the anal canal, squeezes the small blood vessels that feed the tear, and makes every bowel movement painful. Diltiazem lowers that pressure for several hours after each application. With repeated use, the tear gets blood, the pain-spasm cycle loosens, and the edges can grow together.
Because the dose reaching the bloodstream is small, the effects felt elsewhere in the body are usually mild. That is the main reason colorectal surgeons in the UK and many other countries now reach for diltiazem before nitroglycerin. Our diltiazem page covers the drug itself; here we focus on the patient’s side.
Who is diltiazem cream a good choice for?
Diltiazem cream fits most adults with a typical chronic fissure: a single tear in the back or front midline of the anal canal, present for more than 6 to 8 weeks or coming back again and again. It is particularly sensible for:
- People who could not tolerate nitroglycerin because of headaches. Nitroglycerin causes headache in up to half of patients; diltiazem far less often.
- People with migraine or a tendency to headaches, for the same reason.
- Acute fissures with severe pain that are not settling after 1 to 2 weeks of soft stools and sitz baths; your doctor may start a relaxant before the 6-week mark.
- Recurrent fissures, given its lower recurrence rate compared with nitroglycerin in the trials.
It is less obvious, or not the first step, in other situations:
- Children: in a randomized trial of 48 children aged 14 or younger, polyethylene glycol alone improved fissures as much as polyethylene glycol plus topical diltiazem at 12 weeks (Alshehri, 2020). Stool softening comes first; see Anal fissure in children: which creams help, which do not, and why the stool is the treatment.
- Fissures with low sphincter pressure, which some women develop after childbirth: if the muscle is not tight, relaxing it further makes less sense. The ACPGBI 2023 guideline addresses these separately.
- Pregnancy and breastfeeding: a case-by-case decision with your doctor; see Which anal fissure cream is safe in pregnancy and while breastfeeding?.
- Atypical fissures (off the midline, multiple, painless or with a lump): they need an examination before any cream.
Is diltiazem better than nitroglycerin?
For healing, they are roughly equal. For living with the treatment for 8 weeks, diltiazem usually wins. The best summary is a systematic review of 7 randomized trials with 481 patients: diltiazem and nitroglycerin closed chronic fissures equally often, but diltiazem caused fewer headaches (risk ratio 0.39) and fewer recurrences (risk ratio 0.68) (Sajid, 2013).
Put simply, a risk ratio of 0.39 means that, for every 10 patients who got a headache on nitroglycerin, about 4 got one on diltiazem. The Cochrane review of non-surgical therapy reaches a compatible conclusion: calcium channel blockers match the efficacy of nitroglycerin with fewer adverse effects, and nitroglycerin itself is only modestly better than placebo (48.9 % versus 35.5 %).
Where nitroglycerin keeps an advantage is access: it is a licensed product (Rectiv in the US, Rectogesic in the UK and Australia), while diltiazem usually has to be compounded. If you are weighing those brands, read Rectogesic or an alternative? What surgeons weigh before choosing your fissure ointment; for the full three-way comparison, Nifedipine, diltiazem or nitroglycerin: which fissure ointment should you choose?.
How do you use diltiazem cream, step by step?
The routine is simple; the discipline is the hard part. A typical prescription reads "diltiazem 2 % cream, apply two to three times daily for 6 to 8 weeks".
- First application after the morning bowel movement, ideally after a warm sitz bath of 10 to 15 minutes. The second at bedtime; the third, if prescribed, mid-afternoon.
- Clean gently and pat dry. No soap inside the canal, no scrubbing.
- Use a pea-sized amount on a clean fingertip or gloved finger.
- Apply to the anal opening and just inside, up to the first joint of the finger if pain allows. Cream left only on the outer skin cannot reach the sphincter.
- Wash your hands after every application.
Keep the stool soft throughout: fiber (25 to 30 g a day), water, and a softener if needed. Diltiazem relaxes the muscle, but a hard stool can still tear the healing skin. If you miss a dose, apply it when you remember and continue the usual schedule; do not double up. More tips and mistakes to avoid are in How to apply anal fissure cream correctly: where, how much and when.
What should you check at weeks 2, 4 and 8?
Rather than wondering every day whether the cream works, use three checkpoints:
- Week 2: the long ache after bowel movements should be shorter, even if the bowel movement itself still stings. If nothing at all has changed, check how and where you are applying it.
- Week 4: most people are clearly better; bleeding is rare. This is the point where many stop too early. Keep going. If you are not better, go through the list in Four weeks on fissure cream and no better: what to check and what comes next with your doctor.
- Week 8: the fissure should be closed or nearly closed on examination. If it is still open after 8 weeks of correct use, another relaxant cream rarely changes the result; the next steps are botulinum toxin or a lateral internal sphincterotomy (see All guides).
After closure, keep stools soft for several more months. The scar is weaker than normal skin for a while, and one episode of constipation can reopen it.
What side effects does diltiazem cream have?
Most people finish the course without problems. The effects to know about:
- Itching, burning or redness around the anus: the most frequent complaint. It is often mild. If it turns into a spreading rash, stop and see your doctor; it may be contact dermatitis from the drug or the cream base.
- Headache: possible but clearly less frequent than with nitroglycerin, as the trials above show.
- Dizziness or flushing: uncommon at fissure doses.
Tell your doctor before you start if you already take diltiazem or verapamil tablets, beta-blockers or other heart rhythm or blood pressure medicines, or if you have a slow heart rate or low blood pressure. The amount absorbed is small, but your doctor should know. For managing irritation and other effects of fissure creams, see Side effects of anal fissure creams and how to manage them.
Where can you get diltiazem 2% cream in the US, UK, Australia or India?
- United Kingdom: diltiazem 2 % is the cream NHS colorectal teams use most often for chronic fissures. It is usually an unlicensed "special" prescribed by a GP or hospital and made by a specials manufacturer or pharmacy, so it can take a few days to arrive.
- United States: there is no FDA-approved diltiazem rectal product; it is prepared by compounding pharmacies on prescription. Price and base vary by pharmacy.
- Australia: compounded on prescription; nitroglycerin (Rectogesic) is the licensed alternative.
- India: availability varies; some pharmacies stock prepared versions and others compound them. Ask your doctor to write the strength clearly (2 %).
Whatever the country, ask for the same strength and base for the whole course and check the use-by date on the label. Why compounded creams differ between pharmacies, and why they cannot simply be mailed abroad, is explained in Compounded fissure cream: what it is, how to get one and why it doesn’t travel.
When is diltiazem cream not the answer?
A sphincter relaxant treats a typical fissure. It is not a test to see whether something else is going on. See a doctor without delay, before or during treatment, if you notice:
- Bleeding after the age of 45, or blood mixed with the stool.
- Fever, pus or a hot, painful swelling next to the anus, which suggests an abscess.
- A lump that grows, a fissure off the midline, or several fissures at once (possible Crohn’s disease, infection or, rarely, a tumor).
- Unintended weight loss or a change in bowel habit lasting weeks.
And if the fissure is still open after 8 weeks of well-used diltiazem, a surgeon will discuss botulinum toxin or lateral internal sphincterotomy. Our treatment overview shows the full sequence.
Where does FISURIN fit?
FISURIN uses the other calcium channel blocker, nifedipine, combined with lidocaine in a water-based hydrogel, plus a written 6-week protocol. Our surgeons at Clínica Proctológica de Lima prescribe it for chronic and post-operative fissures; it works on the same principle as diltiazem (relaxing the sphincter), and like diltiazem it needs soft stools and the full course, without any promise that every fissure will close. If your doctor has already prescribed diltiazem and it is going well, there is no reason to switch. Today FISURIN is a magistral formula prepared under prescription in Peru and is not shipped abroad; FISURIN Hydrogel and FISURIN Relief are in preparation, with a waiting list by country. See what is inside FISURIN or how to get it where you live.
Frequently asked questions
How long does diltiazem cream take to work?
Pain after bowel movements usually eases in the first one to two weeks. Healing takes 6 to 8 weeks of applications two to three times a day, so keep going after the pain stops.
Is diltiazem cream better than Rectogesic?
Rectogesic is nitroglycerin. In a review of 7 trials, diltiazem healed fissures as often, with fewer headaches (risk ratio 0.39) and fewer recurrences (risk ratio 0.68). Rectogesic is easier to obtain because it is a licensed product.
Can I buy diltiazem cream over the counter?
No. It needs a prescription in the US, UK, Australia and India, and it is usually compounded or supplied as an unlicensed special.
Why does diltiazem cream make me itch?
Local itching or irritation is its most common side effect, from the drug or the cream base. Mild itching often settles; a spreading rash means you should stop and see your doctor.
Do I put diltiazem cream inside the anus?
Yes, at the opening and just inside, up to the first joint of the finger if pain allows. The sphincter it relaxes is inside the anal canal.