At a glance
You were using a topical treatment for your fissure — GTN, diltiazem, or similar — and it was helping. Now it seems to have stopped working, or the improvement you had has reversed. This is a frustrating but recognisable pattern.
This guide covers the common reasons this happens and the practical steps to take.
Common reasons topical treatment loses effectiveness
The fissure has become chronic
If the treatment was managing an acute fissure that has now developed chronic features — fibrosis, a sentinel pile, deep groove — the cream may no longer be sufficient. Chronic fissures often need more intervention than topical treatment alone.
Stool management has slipped
This is the most common and most fixable reason. Over time, dietary habits drift — less fibre, less water, more processed food. A single hard bowel movement can re-tear a healing fissure and undo weeks of progress. If this resonates, refocusing on stool management may restore the treatment’s effectiveness.
The cream was masking rather than healing
Sometimes the topical treatment relaxes the sphincter enough to reduce pain, but the fissure itself was not fully healing. When the treatment is reduced or stops being as effective, the underlying problem becomes apparent again.
Application has changed
Over weeks and months, application technique can drift — less cream, less precise placement, less consistent timing. Small changes in how the cream is applied can affect how well it works.
Tolerance
For some medications, the body can develop a degree of tolerance over extended use, reducing the treatment’s effectiveness. This is more commonly discussed with GTN than with diltiazem.
What to do
Step 1: Review the basics
Before escalating treatment, check:
- Stool management — are you still eating enough fibre and drinking enough water? Are your stools consistently soft?
- Application — are you applying the cream correctly, consistently, at the right frequency?
- Sitz baths — are you still doing them regularly?
- Toilet habits — have you developed any habits (prolonged sitting, straining) that could be re-injuring the fissure?
Addressing a slip in basics can sometimes restore the treatment’s effectiveness.
Step 2: Contact your clinician
If the basics are in place and the treatment has genuinely stopped working:
- Describe what has changed — when the treatment stopped being effective, what the symptoms are now
- Ask about switching topical treatments — if you were on GTN, diltiazem may work, and vice versa
- Ask about the next options — botox, fissurectomy, LIS
- Discuss whether the fissure has become chronic and needs a different approach
Step 3: Understand the options
The common next steps when topical treatment is no longer sufficient:
- Switch creams — try the alternative topical treatment
- Botox injection — delivers sphincter relaxation more directly
- Fissurectomy — removes chronic fissure tissue
- LIS surgery — the most definitive surgical option
Your clinician will recommend based on your specific situation — how long you have had the fissure, what features it has, and your preferences.
The key message
A topical treatment stopping working does not mean you are out of options. It means the condition needs a reassessment and possibly a different level of intervention. The path forward is clearer than it feels — contact your clinician, describe what has changed, and discuss the next step.