Gel, cream, ointment or paste: which form is best for an anal fissure?

What is the difference between a gel, a cream, an ointment and a paste?

Pharmacists call these "vehicles" or "bases". They are the material that carries the active ingredient onto the skin. The same medicine can be prepared in any of them, and the label often uses the words loosely, so it helps to know what each one really is:

"Salve" is an older word for an ointment. In everyday language people say "cream" for all of them, and many nifedipine and diltiazem preparations are labeled "cream" when they are really ointments made in a petroleum jelly base. When you compare products, look at the base listed in the ingredients, not only the word on the front.

Does the base change how well a fissure medicine works?

In theory, yes, a little; in practice, much less than the active ingredient. How much drug leaves the base and reaches the tissue depends on the drug and on the base together, and it has to be tested formula by formula. That is why a well-made preparation matters and why homemade mixes of a crushed tablet in any cream are a bad idea.

What the trials tell us is reassuring. Sphincter relaxants have worked in more than one vehicle:

• A multicenter study of nifedipine gel 0.2 % in acute fissures reported remission in 95 % at 21 days, against 50 % with lidocaine plus hydrocortisone (Antropoli, 1999).
• A randomized double-blind trial of nifedipine 0.3 % with lidocaine 1.5 % ointment in chronic fissures reported healing in 94.5 % at 6 weeks, against 16.4 % in the active control group (Perrotti, 2002).
• Nitroglycerin is sold as an ointment (Rectiv in the US, Rectogesic in the UK, Australia and Europe), and diltiazem 2 % is usually compounded as a cream or ointment. A systematic review of seven randomized trials found diltiazem and nitroglycerin equally effective, with fewer headaches on diltiazem (Sajid, 2013).

These studies did not compare vehicles against each other, and we know of no trial that has. So the honest conclusion is this: the active ingredient (a sphincter relaxant), the strength, and regular use for 6 to 8 weeks decide whether a chronic fissure closes. The base decides how pleasant that is, and that indirectly matters, because a product people dislike gets skipped. For the active ingredients themselves, read Nifedipine, diltiazem or nitroglycerin: which fissure ointment should you choose?.

Which form is more comfortable to use two or three times a day?

A fissure treatment is applied after bowel movements and often before going out to work, so practical details count:

• Greasiness and stains. Ointments and pastes leave grease or white marks on underwear. Gels leave almost nothing once the water evaporates. Creams are in between.
• Spreading on a sore area. A gel or a light cream spreads with a gentle touch, which helps when the anal opening hurts. A stiff ointment needs more pressure, though it softens with body heat.
• How long it stays. Ointments stay in place for hours and keep the skin supple. Gels form a thinner film; that is why the schedule of a gel is as important as the gel itself.
• Stinging. Gels that contain alcohol can sting on broken skin. Water-based hydrogels without alcohol usually do not. Some burning in the first days often comes from the fissure itself, not from the base.
• Irritation and allergy. Creams need emulsifiers and preservatives, and fragrances appear in many over-the-counter products; these occasionally irritate perianal skin. Plain ointments have fewer additives.
• Cleaning. Gels and creams rinse off with water during a sitz bath. Ointments and pastes need oil or gentle soap and more time.

None of this is a reason to give up a medicine that works. If you dislike the feel of a prescribed ointment, ask whether the same active ingredient can be prepared in another base rather than stopping it.

Which form suits which situation with a fissure?

A practical guide we use in clinic:

• Treating the sphincter in a chronic fissure: the form matters less than having nifedipine, diltiazem or nitroglycerin in it. A gel suits people who work outside home or dislike greasy products; an ointment suits people with dry skin or who apply at night.
• Numbing before a bowel movement: lidocaine gels and ointments both work; a gel is easier to rinse off afterward. Lidocaine eases pain but does not close the fissure, as we explain in Lidocaine cream for anal fissure: why it eases the pain but does not close the tear.
• Wet, red or itchy skin around the anus: a zinc oxide paste or cream as a barrier, on the outer skin only. See Zinc oxide and barrier creams for an anal fissure: useful support, not a treatment.
• Lubricating the opening before passing stool: a small amount of plain ointment (petroleum jelly) on the outer edge.
• Suppositories: they melt in the rectum, above the fissure, so most of the medicine never reaches the tear in the lower anal canal. For a fissure, a topical form applied at the opening and just inside makes more sense.

How you apply it matters as much as what you apply. Our guide on How to apply anal fissure cream correctly: where, how much and when covers amount, depth and timing.

What should you read on the label before choosing?

Read in this order:

1. The active ingredient. Is there a sphincter relaxant (nifedipine, diltiazem, nitroglycerin)? If not, the product can relieve symptoms but will not close a chronic fissure, whatever its form. Most hemorrhoid creams fall into this group; see Why hemorrhoid creams do not close an anal fissure (and what does).
2. The strength. Usual strengths are nifedipine 0.2–0.3 %, diltiazem 2 % and nitroglycerin 0.2–0.4 %, applied two to three times a day for 6 to 8 weeks.
3. Anything that should not be there for long. A steroid such as hydrocortisone should never be used for more than 7 days.
4. The base and additives. Water, alcohol, petroleum jelly, fragrance, preservatives. This is where you choose comfort.
5. Storage and expiry. Compounded preparations carry a use-by date set by the pharmacy; keep the container closed, away from heat.

In the US, the UK and Australia, nifedipine and diltiazem for fissures are usually prepared by compounding pharmacies, so the pharmacist chooses the base. Our article on Compounded fissure cream: what it is, how to get one and why it doesn’t travel explains how that works.

When should you stop changing products and see a doctor?

Switching from gel to cream to ointment will not fix a fissure that needs a different treatment. See a doctor without delay if you notice:

After a well-used course of a sphincter relaxant, the next steps are botulinum toxin or a lateral internal sphincterotomy, discussed with a colorectal surgeon. See Four weeks on fissure cream and no better: what to check and what comes next and our page on fissure surgery.

Where does FISURIN fit?

FISURIN is a gel: a water-based hydrogel, without steroids, that carries nifedipine to relax the internal sphincter and lidocaine to ease pain. Our surgeons at Clínica Proctológica de Lima chose a hydrogel because it spreads thinly on a sore area, does not stain and rinses off in a sitz bath, which helps patients keep up two to three applications a day through a 6-week protocol. The base is a matter of comfort; the evidence for the combination comes from trials of nifedipine with lidocaine, not from the vehicle. FISURIN does not replace soft stools, does not act in a few days and does not avoid surgery in every case. 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 FISURIN contains or how to get it where you live.