Referrals of younger patients with ‘painful piles’ who have already applied steroid cream are common.
Ninety per cent of acute anal fissures heal, but in nearly all those that do not, topical steroid cream has been applied to treat presumed piles. There is no evidence that any cream has improved the natural history of piles, but it is recognised that steroids reduce healing of acute fissures, and can create a chronic condition.
Anal fissure can be easily seen without any equipment other than a torch. When a fissure is seen the patient can be told piles are not the cause of their symptoms (a tearing sensation with pain for 30–60 minutes following bowel opening). Avoiding constipation with or without any cream (not containing hydrocortisone) allows healing, but if the problem has not settled in 6 weeks colorectal referral may be required excluding other pathology.