Is four weeks too early to say the cream is not working?
Often, yes. Sphincter-relaxing ointments such as nifedipine, diltiazem or nitroglycerin are prescribed for 6 to 8 weeks because that is how long a chronic fissure usually takes to close. At four weeks, the honest question is not "is the tear gone?" but "is it moving in the right direction?".
Signs that the cream is working even if you can still feel the fissure:
- The pain after a bowel movement lasts minutes instead of hours.
- Bleeding has become occasional or stopped.
- You no longer dread going to the toilet.
- Night-time spasms are rarer.
If you see two or more of these, keep going and reassess at week 8. If nothing at all has changed in four weeks, or things are worse, do not just wait: review the four points below. Our article on All guides explains what a normal course looks like week by week.
Are your stools really soft enough?
This is the first thing we check, because no cream can protect a tear that is stretched open by a hard stool every morning, or irritated by several loose stools a day. Each bad bowel movement reopens what the cream helped close during the previous 24 hours.
What "soft enough" means in practice: a formed but soft stool, passed without straining, ideally once a day. Ask yourself honestly:
- Do you strain or hold your breath on the toilet?
- Are you taking 25 to 30 g of fiber a day, from food plus a supplement such as psyllium, with enough water?
- Do you put off going because you fear the pain?
- Do you have episodes of diarrhea, for example with coffee, alcohol or certain foods?
If the answer to any of these is yes, fix the stools before you blame the cream. A stool softener such as polyethylene glycol (macrogol) is often needed for a few weeks; see All guides and All guides. If diarrhea is frequent or new, that itself needs a medical look.
Are you using the cream the way it was prescribed?
Most people overestimate how many doses they actually apply. Two to three times a day sounds simple until a workday, a trip or a weekend away gets in the way. Check these points honestly:
| Check | What should be happening |
|---|---|
| Doses per day | 2–3 for nifedipine or diltiazem; usually 2 for nitroglycerin. Count the doses you actually applied last week. |
| Where | Just inside the anal opening, up to about 1 cm, not only on the outer skin. |
| How much | A pea-sized amount, about a 2 cm strip on the fingertip, or the measure on your label. |
| When | After the bowel movement and sitz bath, plus at bedtime. |
| The product itself | Within its expiry date, stored as the pharmacy indicated, refilled before it runs out. |
A common hidden problem is stopping a dose because of side effects. If nitroglycerin gave you headaches and you began skipping applications, the cream did not fail; the tolerance did. That is a reason to switch to nifedipine or diltiazem, not to abandon topical treatment. The full technique is in How to apply anal fissure cream correctly: where, how much and when, and how to handle side effects is in Side effects of anal fissure creams and how to manage them.
Could it be something other than a typical fissure?
A typical fissure is a single, painful tear in the back midline of the anal canal (or the front, more often in women) with bright red blood on the paper. When a cream fails, it is worth asking whether that description really fits. Several conditions look like a fissure, or sit alongside one:
- An atypical fissure: off the midline, several at once, very wide or deep, or painless. These can be linked to Crohn’s disease, infections (including sexually transmitted ones), tuberculosis or, rarely, a tumor. See Lateral or multiple anal fissures: when should you think of Crohn’s, HIV, syphilis, tuberculosis or cancer?.
- Crohn’s disease: in a series of 56 patients with Crohn’s, 26 % of fissures that did not heal progressed to an abscess or fistula (Fleshner, 1995). Abdominal pain, diarrhea or weight loss point that way; see Anal fissure and inflammatory bowel disease: how is a Crohn’s fissure different?.
- An abscess or fistula: throbbing pain, swelling, fever or discharge are not features of a simple fissure. Read Fissure, fistula or abscess? How to tell them apart.
- A low-pressure fissure: some fissures, for example after childbirth, occur without a tight sphincter. Relaxing an already relaxed muscle helps less, and the British ACPGBI 2023 guideline addresses these separately.
- Another cause of the pain or bleeding: thrombosed hemorrhoids, skin conditions or, after 45, lesions higher in the bowel that need a colonoscopy.
None of this can be ruled out from home. If the cream has not helped, a proper examination by a colorectal surgeon is the right step, sometimes with an anoscopy or an exam under anesthesia.
Should you switch to a different cream?
Sometimes, but for the right reason. Switching between the three sphincter relaxants makes sense when the problem is tolerance or availability: nitroglycerin causes headache in up to half of patients, while nifedipine and diltiazem are usually better tolerated and heal about as often. Moving from one to another to escape side effects is reasonable, and it restarts the clock for another few weeks of regular use.
Switching makes less sense when a well-tolerated cream was used correctly for 6 to 8 weeks and the fissure is still open. At that point the Cochrane review offers a sobering perspective: nitroglycerin heals only modestly more often than placebo (48.9 % versus 35.5 %), and about half of healed fissures recur. Trying a third and a fourth cream mostly delays the step that has better results. What does not help: adding hemorrhoid creams, prolonging a steroid cream beyond 7 days, or stacking several products at once. Compare the options in Nifedipine, diltiazem or nitroglycerin: which fissure ointment should you choose?.
When is it time for botox or surgery?
If the fissure is still open after 6 to 8 weeks of correct use, with soft stools and a confirmed diagnosis, colorectal guidelines (ASCRS 2023, ACPGBI 2023) recommend moving on. The two options are:
- Botulinum toxin injection. It relaxes the internal sphincter for several months without cutting it. In a classic randomized trial, 96 % of chronic fissures healed at 2 months with botulinum toxin versus 60 % with nitroglycerin, with no fecal incontinence in either group (Brisinda, 1999). It is the usual next step for people who want to avoid surgery. More in All guides.
- Lateral internal sphincterotomy. A small, controlled division of part of the internal sphincter. In a meta-analysis of 18 randomized trials and 1,839 patients, it achieved higher healing than botulinum toxin (Bonyad, 2024). The trade-off is a small risk of minor incontinence, which your surgeon will weigh with you. See All guides.
Neither choice is a failure on your part. Many fissures simply need more than an ointment. Our surgery page and the overview of fissure treatment explain how the decision is made.
Which symptoms mean you should not keep waiting?
Whether or not the cream is helping, see a doctor without delay if you notice any of these:
- Bleeding after the age of 45, or blood mixed with the stool, especially if you have never had a colonoscopy.
- Fever, pus, or a throbbing, swollen lump next to the anus (possible abscess).
- A lump that grows, a fissure off the midline, or several fissures at once.
- Unintended weight loss, persistent diarrhea or abdominal pain.
- Pain that keeps getting worse despite correct treatment.
Where does FISURIN fit?
FISURIN is the nifedipine and lidocaine hydrogel our surgeons at Clínica Proctológica de Lima prescribe as the first step for chronic and post-operative fissures, with a written 6-week protocol that includes the stool and application checks described above and a scheduled review at the end. It does not fix hard stools, does not replace an examination when the fissure looks atypical, and, like any ointment, will not close every chronic fissure; when it does not, our surgeons move on to botulinum toxin or sphincterotomy. Today it 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. See what is inside FISURIN or how to get it where you live.
Frequently asked questions
How long should I use fissure cream before giving up?
Six to eight weeks of regular use, two to three times a day. At four weeks, look for less pain and bleeding rather than full closure. If nothing at all has changed by then, review stools, doses and technique and see a doctor.
Why is my anal fissure not healing with cream?
The usual reasons are hard stools or diarrhea, missed doses, applying the cream only on the outer skin, stopping because of side effects, or a diagnosis that is not a simple fissure.
Should I switch from nitroglycerin to diltiazem or nifedipine?
If nitroglycerin causes headaches that make you skip doses, yes: nifedipine and diltiazem heal about as often with fewer headaches. If a well-tolerated cream failed after 8 weeks, the next step is usually botox or surgery, not another cream.
Is botox better than cream for a fissure?
For fissures that did not close with cream, botulinum toxin is the usual next step. In one randomized trial it healed 96 % at 2 months versus 60 % with nitroglycerin.
Can a fissure that does not heal be something else?
Yes. Fissures off the midline, multiple or painless ones can be linked to Crohn’s disease, infections or, rarely, a tumor. An examination by a colorectal surgeon is the way to know.