At a glance
Some clinicians prescribe a single cream that combines nifedipine with lidocaine. Some add a third ingredient, diclofenac. These are made to order by a compounding or specials pharmacy, not bought off the shelf.
The idea is to do two jobs at once:
- Nifedipine relaxes the internal sphincter and may improve blood flow to the fissure. This is the part aimed at healing, and it works slowly.
- Lidocaine numbs the area. This is the part aimed at pain, and it works quickly.
- Diclofenac, when added, is an anti-inflammatory painkiller.
What people report most is that the numbing can arrive long before any healing does. That gap causes a lot of confusion. This page explains why it happens and what people commonly ask along the way.
For compounding in general, see our guide to compounded medicines for fissures.
Why it is prescribed
People describe being offered the combination for a few reasons:
- Pain is the main problem. When every bowel movement is severe, a cream that also numbs feels more bearable to use.
- GTN did not suit them. Nifedipine tends to cause fewer headaches than GTN.
- It is their clinic’s usual product. In the US, some surgeons prescribe this mix routinely.
- It is one step before procedures. Many are told it is worth a fair try before discussing Botox or surgery.
The nifedipine and lidocaine combination has been tested in a small number of clinical trials and is commonly prescribed in some countries, particularly the US. The added diclofenac version has much less research behind it. It is prescribed on clinical judgement rather than strong evidence.
Numbing versus healing
This is the pattern people describe most often.
The first days. Many notice the sharpness after bowel movements eases. Some feel very little change at first. Accounts of the first week are mixed.
The first weeks. Pain is often lower, but bleeding or a brief sting with each bowel movement may carry on. People wonder whether it is working.
Six to eight weeks and beyond. This is when people more often describe real change, or decide with their clinician that it has not helped enough.
Why this matters:
- Lidocaine can mask pain from a tear that has not changed. Feeling better is good news, but it is not the same as healed. Numbing can also hide pain from something new, such as an abscess. Fever, swelling, discharge or a lump still need checking even if the area feels fine.
- Pain that returns as soon as a dose wears off is common, and it does not mean the cream has failed.
- Stopping early because the numbing “is not enough” is a common regret. So is stopping early because things feel fine.
People who found their way through this stage often say keeping a short daily note helped. Bleeding, pain score and stool type, a line a day, made it easier to see a trend and to show their clinician.
Side effects people report
From the nifedipine:
- Headache, flushing or light-headedness, usually milder than with GTN
- Rarely, palpitations or chest discomfort, which needs urgent attention
From the lidocaine:
- A sting or burn as it first goes on, before the numbness starts
- Some develop a sensitivity over time. People describe a burning or swollen, pressured feeling that gets worse with each use.
From the diclofenac:
- Local irritation is the main thing people mention.
- Anti-inflammatory painkillers are not suitable for everyone, which is why your prescriber needs your full medical history.
From the base:
- Petroleum jelly bases feel greasy and warm. Cream bases can feel cooler and absorb faster.
- Some people react to the base rather than any active ingredient.
When a reaction happens, it is often hard to tell which ingredient is responsible. A common solution described is asking for the compound to be remade without lidocaine. Some people then tolerate it well.
If you also use other creams, like a separate steroid or numbing product, tell your prescriber. Steroid creams in particular can thin the skin with longer use. See our guide on steroid cream overuse.
Compounding pharmacy practicalities
People’s accounts are full of practical snags. The common ones:
- Not every pharmacy compounds. Calling ahead saves trips. Some need a day or more to make it.
- Check the label against what you expected. Some people have found the pharmacy made a different mix from the one their doctor described. If the ingredients listed are not what you were told, ask before using it.
- Read the use-by date. Compounded creams often have a short shelf life. Some need to be kept cool. Follow the storage instructions on the label.
- Texture should be smooth. Grittiness suggests uneven mixing. It is fair to ask the pharmacy about their method.
- Batches can differ. A new pharmacy, or even a new batch, may feel different.
- Cost and cover vary. In the US, insurance cover for compounds is inconsistent and has changed over time. Ask the pharmacy for a price before it is made.
- “For external use” labels. These sometimes conflict with what the prescriber said about where to apply it. Ask your prescriber which they mean. Our practical guide to nifedipine cream covers this.
When to seek care
Get urgent help (go to A&E or an emergency department, or call 999 in the UK or 911 in the US) if you have:
- Heavy bleeding, or bleeding that will not stop
- Fever with pain, swelling or discharge around the anus
- Severe pain that is getting worse rather than better
- Chest pain, a racing heartbeat, fainting, or swelling of the face or lips after using the cream
See your GP or prescriber soon if:
- Burning or swelling gets worse with each use
- A rash or blistering develops
- There has been no real change after the course you were given
- You are unsure what is in your compound or how to use it
- Bleeding that is dark, mixed into the stool, or happens without pain
- A change in bowel habit lasting more than a few weeks, or narrower stools
- Unexplained weight loss, or a lump