BNF for Children 2011-2012

66 1.7 Local preparations for anal and rectal disorders BNFC 2011–20121 Gastro-intestinal system1.7 Local preparations foranal and rectal disorders1.7.1 Soothing anal and rectal preparations1.7.2 Compound anal and rectalpreparations with corticosteroids1.7.3 Rectal sclerosants1.7.4 Management of anal fissuresIn children with perianal soreness or pruritus ani, goodtoilet hygiene is essential; the use of alcohol-free ‘wetwipes’after each bowel motion, regular bathing and theavoidance of local irritants such as bath additives isrecommended. Excoriated skin is best treated with aprotective barrier emollient (section 13.2.2); in childrenover 1 month, hydrocortisone ointment or cream (section13.4) or a compound rectal preparation (section1.7.2) may be used for a short period of time, up to amaximum of 7 days.Pruritus ani caused by threadworm infection requirestreatment with an anthelmintic (section 5.5.1). Topicalapplication of white soft paraffin or other bland emollient(section 13.2.1) may reduce anal irritation causedby threadworms.Perianal erythema caused by streptococcal infectionshould be treated initially with an oral antibacterialsuch as phenoxymethylpenicillin (section 5.1.1.1) orerythromycin (section 5.1.5), while awaiting results ofculture and sensitivity testing.Perianal candidiasis (thrush) requires treatment with atopical antifungal preparation (section 13.10.2). Fortreatment of vulvovaginal candidiasis, see section 7.2.2.Proctitis associated with inflammatory bowel disease inchildren is treated with corticosteroids and aminosalicylates(section 1.5).For the management of anal fissures, see section 1.7.4.1.7.1 Soothing anal and rectalpreparationsHaemorrhoids in children are rare, but may occur ininfants with portal hypertension. Soothing rectal preparationscontaining mild astringents such as bismuthsubgallate, zinc oxide, and hammamelis may providesymptomatic relief, but proprietary preparations whichalso contain lubricants, vasoconstrictors, or mild antisepticsmay cause further perianal irritation.Local anaesthetics may be used to relieve pain inchildren with anal fissures or pruritus ani, but localanaesthetics are absorbed through the rectal mucosaand may cause sensitisation of the anal skin. Excessiveuse of local anaesthetics may result in systemic effects,see section 15.2. Preparations containing local anaestheticsshould be used for no longer than 2–3 days.Lidocaine ointment (section 15.2) may be appliedbefore defaecation to relieve pain associated with analfissure, but local anaesthetics can cause stinging initiallyand this may aggravate the child’s fear of pain.Other local anaesthetics such as tetracaine, cinchocaine(dibucaine), and pramocaine (pramoxine) may beincluded in rectal preparations, but these are moreirritant than lidocaine.Corticosteroids are often combined with local anaestheticsand soothing agents in topical preparations forhaemorrhoids and proctitis. Topical preparations containingcorticosteroids (section 1.7.2) should not be usedlong-term or if infection (such as herpes simplex) ispresent. For further information on the use of topicalcorticosteroids, see section 13.4.1.7.2 Compound anal and rectalpreparations withcorticosteroidsAnugesic-HC c (Pfizer) ACream, benzyl benzoate 1.2%, bismuth oxide 0.875%,hydrocortisone acetate 0.5%, Peru balsam 1.85%,pramocaine hydrochloride 1%, zinc oxide 12.35%. Netprice 30 g (with rectal nozzle) = £3.71DoseHaemorrhoids, pruritus ani. By rectumChild 12–18 years apply night and morning and after abowel movement; do not use for longer than 7 daysSuppositories, buff, benzyl benzoate 33 mg, bismuthoxide 24 mg, bismuth subgallate 59 mg, hydrocortisoneacetate 5 mg, Peru balsam 49 mg, pramocainehydrochloride 27 mg, zinc oxide 296 mg, net price 12= £2.69DoseHaemorrhoids, pruritus ani. By rectumChild 12–18 years insert 1 suppository night andmorning and after a bowel movement; do not use forlonger than 7 daysAnusol-HC c (McNeil) AOintment, benzyl benzoate 1.25%, bismuth oxide0.875%, bismuth subgallate 2.25%, hydrocortisoneacetate 0.25%, Peru balsam 1.875%, zinc oxide10.75%. Net price 30 g (with rectal nozzle) = £3.29DoseHaemorrhoids, pruritus ani. By rectumChild 12–18 years apply night and morning and after abowel movement; do not use for longer than 7 daysSuppositories, benzyl benzoate 33 mg, bismuth oxide24 mg, bismuth subgallate 59 mg, hydrocortisoneacetate 10 mg, Peru balsam 49 mg, zinc oxide 296 mg.Net price 12 = £2.31DoseHaemorrhoids, pruritus ani. By rectumChild 12–18 years insert 1 suppository night andmorning and after a bowel movement; do not use forlonger than 7 daysPerinal c (Dermal)Spray application, hydrocortisone 0.2%, lidocainehydrochloride 1%. Net price 30-mL pack = £6.11DoseHaemorrhoids, pruritus ani. By rectumChild 2–18 years spray once over the affected area upto 3 times daily; do not use for longer than 7 days withoutmedical advice (child under 14 years, on medical adviceonly)