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238 Hemorrhoids and perianal pain
Crohn’s disease, topical metronidazole (10%), may provide significant relief
but is also best instituted only in close conjunction with follow-up providers.
38 One difference with Crohn’s disease, compared with other perianal
conditions, is that anti-diarrheals may actually be indicated if severe diarrhea
risks causing hemorrhoidal prolapse.
Perianal pain may also be the presenting complaint for patients with
Condylomata acuminatum. Repeated application of topical caustics (e.g.
trichloroacetic acid, liquid nitrogen) or other agents such as isotretinoin or
interferon may relieve pain, but prescription and use of these agents (as well
as the usually necessary surgical intervention) fall outside the scope of the ED
provider. 39,40
The systemic condition lichen sclerosus, usually treated with potent topical
corticosteroids, causes perianal (and vulvar) pain that can be significantly
alleviated with topical 1% pimecrolimus cream. 41 There is no systemic
absorption of the pimecrolimus, and the authors conclude that lichen sclerosus
can be effectively relieved without resort to potent corticosteroids. 41
The unfamiliarity of most ED providers with lichen sclerosus (not to mention
pimecrolimus) means that institution of therapy for the disease should occur
as part of a long-range care plan.
Proctosis fugax is a poorly understood disease in which acute perianal pain
of short duration occurs in the absence of organic disease or previous
perianal surgery. While there are no RCT data to guide therapy, noncontrolled
analysis indicates that topical nitroglycerin or sublingual nifedipine
(10 mg) provide relief in about half of patients. 42
n Summary and recommendations
First line: fiber-containing laxative (e.g. psyllium powder 5–15 mL PO QD–
TID); topical diltiazem gel (700 mg of a 2% preparation applied BID)
Reasonable: other topical calcium channel blocker (e.g. nifedipine 0.3%
preparation applied BID)
Pregnancy: fiber-containing laxative (e.g. psyllium powder 5–15 mL PO
QD–TID)