Why hemorrhoid creams do not close an anal fissure (and what does)

Why do so many people put hemorrhoid cream on a fissure?

Because the pain is in the same place, the pharmacy shelf is labeled "hemorrhoids", and almost everyone assumes that anything wrong down there is a hemorrhoid. In our clinic, most patients with a fissure arrive having used at least one hemorrhoid cream, often for weeks.

The confusion is understandable. Both problems can bleed bright red blood, both hurt when you sit, and both can come with a small lump at the anal opening. But they are different diseases with different mechanics. Hemorrhoids are swollen vascular cushions. A fissure is a tear in the anoderm, the thin lining of the lower anal canal. You can see the full comparison on our fissure vs hemorrhoids page and in Fissure or hemorrhoids? The pain rule that tells them apart.

The clearest clue is the type of pain. A fissure causes a sharp, cutting pain during the bowel movement, often described as passing glass, followed by a burning or throbbing ache that can last minutes to hours. Hemorrhoids are more often painless bleeding, a feeling of fullness or a lump that comes out and goes back in. A thrombosed hemorrhoid hurts, but as a constant, tender lump, not a tear that hurts every time you go.

What is actually in a hemorrhoid cream?

Brands differ by country, but most hemorrhoid creams and ointments sold in the US, the UK, Australia and India are built from the same four families of ingredients:

Look for what is missing from that table: there is no ingredient that relaxes the internal anal sphincter. That is the one action a fissure needs.

Why can’t a hemorrhoid cream close a fissure?

A fissure stays open because of a cycle. The tear hurts, the pain makes the internal sphincter contract, the tight sphincter squeezes the small arteries that feed the back of the anal canal, and the poorly supplied tear cannot heal. This is why guidelines describe the chronic fissure as a problem of a tight sphincter, not of swollen veins.

To break that cycle, you need to lower sphincter pressure for long enough for new tissue to cover the wound, usually 6 to 8 weeks, while soft stools avoid tearing it again. Hemorrhoid creams work on veins and skin. The anesthetic can reduce the pain-triggered spasm a little for an hour or two, but it wears off long before the next bowel movement. The vasoconstrictor, in theory, goes in the opposite direction to what the tear needs, since the problem is already poor blood flow. And the steroid, used for weeks, thins the very skin that is trying to heal.

The evidence matches the mechanism. In a multicenter study of acute fissures, a 0.2 % nifedipine gel achieved remission in 95 % of patients at 21 days, against 50 % with an ointment of lidocaine plus hydrocortisone (Antropoli, 1999), a combination close to what many hemorrhoid creams contain. In the classic BMJ study of first-episode acute fissures, lidocaine ointment alone healed 60 % at 3 weeks, compared with 87 % with warm sitz baths plus bran (Jensen, 1986). Numbing is not healing.

Is it ever reasonable to use a hemorrhoid cream with a fissure?

Yes, with clear limits. A hemorrhoid cream is not dangerous for a few days, and some situations justify it:

• You have both problems. Fissures and hemorrhoids often coexist, especially after pregnancy or long constipation. A doctor can treat each one with what it needs.
• Short relief while you start real treatment. A few days of an anesthetic-containing cream can make bowel movements less frightening while fiber and sitz baths start to work.
• Itchy, irritated skin around the anus, for a short course.

Three limits: if the cream contains hydrocortisone, never more than 7 days (we explain why in Hydrocortisone cream for an anal fissure: when it helps and why never more than 7 days); do not use several products at once; and if after a week the pain during and after bowel movements has not improved, stop and change strategy rather than switching to another hemorrhoid brand. If all you want is comfort, a plain lidocaine gel or a zinc oxide barrier cream does the job with fewer ingredients. See Lidocaine cream for anal fissure: why it eases the pain but does not close the tear and Zinc oxide and barrier creams for an anal fissure: useful support, not a treatment.

What should you use instead to close the fissure?

The steps that close a fissure are less exciting than a pharmacy aisle, but they work:

1. Soft, formed stools every day. 25 to 30 g of fiber, ideally psyllium, and enough water. Hard stools reopen the tear no matter which cream you use. Our guide to All guides explains how to build up the dose.
2. Warm sitz baths for 10 to 15 minutes after bowel movements, which relax the sphincter and clean without rubbing.
3. A sphincter-relaxing ointment if the fissure is severe or has lasted more than a few weeks: nifedipine or diltiazem 2 to 3 times a day for 6 to 8 weeks, or nitroglycerin 0.2 to 0.4 % (Rectiv in the US; Rectogesic in the UK and Australia), which causes headache in up to half of patients. The Cochrane review found that calcium channel blockers match nitroglycerin’s efficacy with fewer adverse effects.
4. A colorectal surgeon if the fissure is still open after 6 to 8 weeks of correct treatment: botulinum toxin or a lateral internal sphincterotomy are the next steps.

For a full head-to-head of the three relaxing ointments, read Nifedipine, diltiazem or nitroglycerin: which fissure ointment should you choose?. Our treatment page lays out the whole path.

When should anal pain or bleeding not be self-treated?

Hemorrhoid creams are often used to "manage" symptoms that deserve a proper look. See a doctor without delay if you notice:

A fissure that does not fit the typical picture, or does not close with proper treatment, can be a sign of Crohn’s disease, infection or, rarely, a tumor. Meeting a colorectal surgeon early saves months of trial and error.

Where does FISURIN fit?

FISURIN is not a hemorrhoid cream. It combines a sphincter relaxant (nifedipine) with a local anesthetic (lidocaine) in a water-based hydrogel, prescribed by our surgeons at Clínica Proctológica de Lima for chronic and post-operative fissures with a written 6-week protocol. It targets the sphincter spasm that hemorrhoid creams miss, but it does not replace soft stools and cannot promise closure in every case. Today FISURIN is a magistral formula prepared under prescription in Peru and is not shipped abroad; FISURIN Hydrogel (medical device) 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.