Clinical question
How effective are topical treatments (calcium channel blockers [CCBs], nitrates, and vitamin E) for chronic anal fissures in adults?
Bottom line
Healing rates with topical nitroglycerin are roughly 60% versus 40% with placebo at 8 weeks. Topical CCBs are at least as good as nitroglycerin, with a lower risk of headache (7% versus 56%). Based on 1 RCT, topical vitamin E may be superior to nitroglycerin (86% versus 66% healed at 8 weeks).
Evidence
Five meta-analyses of RCTs from the past 10 years were identified.1-5 Adjunctive treatments were usually unclear (often fibre therapy or dietary advice). Healing was defined based on examination findings or patient report. Results were statistically significant unless indicated.
Calcium channel blockers (eg, 2% diltiazem ointment): In 3 systematic reviews (1 to 7 RCTs, 60 to 727 patients), at about 6 weeks, 78% to 82% of patients were healed with CCBs versus 33% to 42% with control; number needed to treat (NNT)=3 (1 of the 3 analyses was not statistically different).1-3
- Calcium channel blockers versus nitroglycerin: In 11 RCTs (770 patients), at 8 weeks, 79% of patients were healed with CCBs versus 65% with nitroglycerin.1 Similar results were found in other systematic reviews3-5 but were statistically different in only 1.3
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-In 10 RCTs (590 patients), 7% had headache with CCBs versus 56% with nitroglycerin.1
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Vitamin E: In 1 RCT (160 patients, twice daily treatment),6 at 8 weeks, 86% were healed with vitamin E versus 66% with nitroglycerin; NNT=5. None stopped vitamin E owing to headache versus 18% with nitroglycerin.
Limitations: Some reviews included pediatric populations or did not include all RCTs. Many RCTs were unblinded, underdosed nitroglycerin, or had unclear vitamin E doses.
Context
Guidelines recommend topical CCBs.7 Botulinum toxin injections and surgery are options for treatment failure, but fecal incontinence is possible.7
For an 8-week treatment, compounded topical CCBs or nitroglycerin cost roughly $60 per 30 g (personal communication from Stacy Jardine, Clinical Pharmacist, Peace River Value Drug Mart in Peace River, Alberta; 2022). Commercially available vitamin E ointment costs about $10 per 50 g.8
Implementation
Anal fissures are commonly found in middle-aged adults and in children.9 They are primarily diagnosed by clinicians, with symptoms including pain during or after passage of stool, rectal bleeding, and linear tear (with or without a sentinel tag).10 Most fissures are at the midline. Fissures not in the midline should be investigated for secondary causes (eg, Crohn disease).11 Differential diagnosis of severe anal pain includes fissure, thrombosed hemorrhoids, or perirectal abscess.9 Rectal bleeding is not necessarily diagnostic of malignancy but requires assessment and consideration of other risks factors.12
Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice@cfpc.ca.
Footnotes
Competing interests
None declared
References
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