Ointments for hemorrhoids

Hemorrhoids are not just "veins," but rather a change in the normal hemorrhoidal "cushions" of the anal canal. When their supporting structure weakens and mechanical stress increases (straining, prolonged sitting), the cushions shift, become engorged with blood, and can bleed, itch, prolapse, or thrombose. Ointments and creams are not needed to "correct the anatomy," but to reduce pain, itching, and swelling, protect the skin, and help you comfortably survive a flare-up while you establish soft stools and adjust your habits. This is the approach taken by modern hemorrhoid management guidelines. [1]

Topical treatments work "here and now," but their effect is primarily symptomatic. The anatomical problem (severe internal prolapse, mixed nodes, thrombosed external nodes) is addressed through behavioral measures, normalizing bowel movements, and, when indicated, office or surgical techniques. Therefore, in treatment regimens, ointments are part of a "combo approach" rather than a standalone "cure-all." [2]

It's important to distinguish between internal and external components. For external lesions (skin at the anal margin), ointments or creams are often preferable to suppositories, as the application site is the skin, which is rich in pain receptors. For internal lesions, suppositories and procedures are discussed after an examination. This distinction is directly reflected in clinical practice. [3]

Finally, "scarlet blood on paper" isn't a reason to automatically chalk it up to hemorrhoids. Especially in older people or those on anticoagulants, a doctor's evaluation is required: guidelines insist that the symptom not be ignored. Ointments can reduce itching and inflammation, but won't solve the problem if the source of the blood is different. [4]

Table 1. Real purposes of ointments and creams for hemorrhoids

Task	What does the ointment actually do?	What not to expect
Relieve pain and itching	Anesthetic and anti-inflammatory components reduce symptoms	"Remove" the nodes anatomically
Reduce swelling	Short courses of steroids reduce inflammation	Long-term effect without behavior change
Protect your skin	Barrier and emollient bases reduce maceration	Quick effect without parallel hygiene
Coping with an exacerbation more comfortably	Yes, as part of the overall plan (behavior + stool)	Complete control of relapses without changing habits [5]

How and why ointments work: mechanisms and limitations

Topical anesthetics (most commonly lidocaine) block the conduction of pain fibers in the skin and mucous membranes, quickly reducing pain and itching. The effect occurs within an hour and lasts for several hours; it serves as a "bridge" through the acute phase, rather than a treatment for the underlying cause. Reliable patient sources and clinical guidelines confirm the appropriateness of short courses of lidocaine as part of rectal preparations. [6]

Corticosteroids (hydrocortisone in creams, ointments, and suppositories) reduce inflammation and swelling. The UK National Health Service clearly states that hydrocortisone can be used for hemorrhoids, including during pregnancy and breastfeeding, because systemic absorption is low. However, courses should be short and doses minimal to avoid thinning the skin. This is the "golden rule" of safety for topical steroid therapy. [7]

Vasoconstrictor components (such as phenylephrine), present in some combination ointments, theoretically reduce swelling through local vasoconstriction. However, high-quality data on their benefits is limited, and the safety data for pregnant women is limited, so they are not considered first-line treatments and are recommended for use with caution and only as directed by a physician. [8]

Combination formulations of a venotonic plus anesthetic (e.g., tribenoside + lidocaine) have been shown in clinical studies to provide rapid relief of pain and itching in patients with hemorrhoids and are well-tolerated; such medications are appropriate as part of conservative therapy. However, the general rule also applies to them: short courses and simultaneous work on bowel habits and habits. [9]

Table 2. Main classes of components in hemorrhoid ointments

Class	Mechanism	When appropriate	Restrictions
Anesthetics (lidocaine)	Block pain conduction	Sharp pain, itching	Symptomatic effect only; short courses [10]
Corticosteroids (hydrocortisone)	Anti-inflammatory and anti-edematous effect	Severe inflammation of the skin	Short courses, risk of thinning of the skin with long-term use [11]
Vasoconstrictors (phenylephrine)	Vasoconstriction, reduction of edema	Complementary means	Limited evidence base; caution in pregnancy [12]
Combined (tribenoside + lidocaine, etc.)	Venotonic + pain relief	Rapid relief with conservative treatment	Course application, does not replace work with a chair [13]

When is ointment the best choice and when is it not?

For external cases (nodules and inflammation of the skin at the anal margin), ointments/creams are more logical than suppositories: the point of application is the skin, not the anal canal. A short course of anesthetic will reduce pain, hydrocortisone will reduce swelling and itching, and barrier agents will reduce maceration. After the symptoms subside, care and relapse prevention are recommended. This "skin" focus is consistent with practical recommendations. [14]

For internal nodes (above the dentate line), the leading symptoms are bleeding and prolapse. In these cases, suppositories and office methods (ligation, coagulation, sclerotherapy) are discussed after anoscopy. Ointments remain adjunctive—for example, for the care of irritated perianal skin. The choice of basic tactics is dictated by the guidelines of the American Society of Colorectal Surgeons. [15]

In the case of external node thrombosis, the time factor is important. If severe pain has recently begun (usually within 48-72 hours), outpatient node excision under local anesthesia is considered for rapid relief. If the "window" has passed or the pain is subsiding, a conservative approach is reasonable, with ointments (lidocaine ± a short-acting steroid) helping to survive the acute phase. This is reflected in current guidelines. [16]

If there is profuse scarlet blood, weakness, dizziness, or an irreversible, painful prolapse, and ointments don't resolve the problem, an in-person assessment and, if necessary, instrumental methods are required. In such situations, safety is more important than symptomatic "masking." [17]

Table 3. Where the ointment is the base, and where it is only an addition

Situation	The role of ointment/cream	What else is required?
External form, dermatitis	The basis of symptom control	Hygiene, barrier care, soft stool
Internal nodes (blood, prolapse)	Auxiliary (skin)	Anoscopy, office methods according to indications [18]
External node thrombosis ≤ 72 h	Relief before/after the mini-procedure	Consider outpatient excision [19]
Red Flags	Not indicated as monotherapy	Urgent in-person assessment

Safety and special groups: pregnancy, breastfeeding, polypharmacy

During pregnancy, topical hydrocortisone and lidocaine are acceptable when used correctly: systemic absorption is minimal, and short courses are considered safe. The UK National Health Service emphasizes the absence of proven harm when used rationally. Vasoconstrictors (phenylephrine) are not first-line treatment due to limited data; use only as directed by a physician. [20]

During breastfeeding, lidocaine and hydrocortisone in rectal forms are also acceptable for short courses; general recommendations include using the lowest effective dose, avoiding application to broken skin, and thoroughly washing off any residue before feeding if applied to skin areas with a risk of contact. The safety profile is covered by national and professional sources. [21]

Patients on anticoagulants and antiplatelet agents should exercise caution: even slight bleeding with topical medications is a reason to evaluate drug interactions and the underlying cause of bleeding. Topical medications themselves rarely increase systemic risk, but the management of hemorrhoidal bleeding in patients on such medications should be medically guided, not pharmaceutically prescribed. [22]

Long-term, uncontrolled use of topical steroids in folds of skin leads to thinning and irritant dermatitis. NHS guidelines and materials insist that courses should be short, and if itching and oozing are persistent, hygiene factors (wet wipes, prolonged sitting) should be addressed first, rather than "enhancing the hormone." [23]

Table 4. What is important to remember about the safety of ointments

Situation	What is acceptable	What to avoid	Base
Pregnancy	Lidocaine, hydrocortisone - in short	Phenylephrine without a prescription	NHS: Safe in short courses, minimum dose [24]
Breast-feeding	The same means in short	Application to damaged skin, long courses	Practical recommendations for drugs
Anticoagulants	Careful symptom therapy + medical blood assessment	Self-cancellation of vital drugs	ASCRS, clinical tactics [25]
Long-term steroids	Not recommended	Courses "for months"	NHS: Risk of thinning skin [26]

The role of normalizing stool: without this, ointments "work at half strength"

Soft, formed stools without straining are the foundation of any regimen. The 2023 joint guidelines of the American Gastroenterological Association and the American College of Gastroenterology recommend polyethylene glycol (macrogol) as the first-line pharmacotherapy for chronic constipation, followed by on-demand stimulants, and, in cases of resistance, secretagogues and serotonin receptor agonists. For a patient with hemorrhoids, this means starting with osmotic laxatives, water, and fiber, and then evaluating the benefits of ointments. [27]

Lactulose is an alternative to macrogol; it sometimes causes gas, but some people tolerate it better. Stimulant laxatives (bisacodyl, picosulfate) are appropriate as a "rescue" in short courses. All of these reduce friction and the need to strain—a key trigger of pain, itching, and bleeding. [28]

In addition to medication, brief visits to the toilet when you actually need to, avoiding "sleep-watching" your smartphone, warm sitz baths, and barrier skin care can reduce blood stagnation in the stools and maceration. These simple steps often contribute more to symptom control than changing ointments. [29]

It's precisely against the backdrop of "proper bowel movements" and hygiene that topical treatments demonstrate maximum effectiveness: anesthetics are needed less frequently, steroids are used in short courses, and the skin heals without chronic dermatitis. This "combo approach" follows directly from the guidelines. [30]

Table 5. "Ladder" for stool in hemorrhoids (according to AGA/ACG)

Step	What are we doing?	When to move on
1	Water, fiber, macrogol daily	If after 1-2 weeks the stool is still “dry”
2	Add an on-demand stimulant	Frequent need → revision of the basis
3	Secretagogues/5-HT4 agonists (as prescribed by a physician)	Resistance to steps 1-2
Any stage	Warm baths, short visits, barrier care	Always as a "background" [31]

How to use ointments correctly: step by step and without mistakes

Apply a thin layer of ointment to clean, gently dried skin. Avoid occlusion (tight dressings) in the intergluteal area to avoid increased maceration and absorption. Wash your hands before and after application; clean applicators according to the instructions. These guidelines are detailed in NHS materials and clinical leaflets. [32]

For anesthetics, stick to short courses: a few days during the acute phase, then only as needed. If the burning sensation intensifies or a rash develops, discontinue the medication and consider an alternative. This "minimally sufficient" approach reduces the risk of irritation. [33]

Steroids are prescribed under even stricter guidelines: a short course at the minimum effective dose, followed by a transition to barrier care and non-drug measures after the inflammation subsides. Long-term "maintenance" use in skin folds is contraindicated due to the risk of atrophy. [34]

For mixed nodules and irritation around the anus, it's wise to alternate treatments: a barrier cream in the morning, a topical anesthetic if pain occurs, and a short evening course of steroid cream if inflammation is severe. However, if symptoms persist for weeks, an examination is necessary: a fissure, proctitis, or another condition may be present. [35]

Table 6. Typical errors and substitutions

Error	What is dangerous?	What to replace it with
Long courses of steroids "just in case"	Thinning of the skin, dermatitis	Short course → barrier care and baths [36]
Candles for external use instead of cream	Low efficiency	Cream/ointment for skin + work with stool
"Sitting out" on the toilet with a smartphone	Blood stasis, edema	≤ 3-5 minutes as needed, with a footrest
Ignore significant blood	Risk of missing another source	In-person assessment, if indicated - endoscopy [37]

Combinations and "new" approaches: what the evidence says

Lidocaine and hydrocortisone combinations are well-tolerated and effective for short-term pain and inflammation control, as confirmed by clinical guidelines and practice reviews. They are convenient when rapid symptom relief is needed and the number of applications required is reduced, but the duration remains short. [38]

The combination of tribenoside and lidocaine has been shown in clinical studies to rapidly reduce pain, itching, and discharge in patients with hemorrhoids; in some countries, it is also used in pregnant women after the first trimester for individual indications. In any case, it is not a substitute for bowel and behavioral modification. [39]

In cases of concomitant anal fissure, it's important to consider that the pain may originate "not only from pillows." In such cases, specialized ointments containing nitrates or calcium channel blockers (such as glyceryl trinitrate or diltiazem) are appropriate—but this is a separate tactic prescribed by a doctor; they are not considered "hemorrhoid remedies" per se. [40]

Data on the benefits of vasoconstrictor components are limited; safety concerns (especially during pregnancy) mean that such formulations are not considered first-line standard. If they are used at all, it is briefly and as indicated when alternatives are not available. [41]

Table 7. Combined and related approaches

Approach	For what	What is known	Note
Lidocaine + hydrocortisone	Rapid relief of pain and swelling	Good tolerability, convenience	Short courses, then care [42]
Tribenoside + lidocaine	Symptom control with conservative tactics	Randomized and observational data	Does not replace chair work [43]
Nitrates/calcium channel blockers	With an accompanying crack	Effective for fissures, not hemorrhoids	As prescribed by a doctor [44]
Vasoconstrictors (phenylephrine)	Theoretically, they reduce swelling	Limited base, caution in pregnancy	Not the first line [45]

Selection algorithm: “if… then…” (without brands, by active ingredients)

If the main symptom is pain and itching in the external form, start with a short course of lidocaine, add warm sitz baths and barrier care; if skin inflammation is severe, try a short course of hydrocortisone. After 5-7 days, assess the need for continuation. [46]

If the leading symptom is bleeding without severe pain, an examination is needed (to rule out a fissure or other sources), stool support (macrogol), and, if internal nodes are typical, a discussion of office procedures. Ointments in this situation are merely a skin support, not a primary treatment. [47]

If a sharp, painful lump appears at the anal margin (suspected of external anus thrombosis), outpatient excision is considered within the first 48-72 hours; if a conservative approach is chosen, lidocaine, a short-term steroid injection, baths, and soft stools are used. Symptoms usually subside within 1-2 weeks. [48]

If you are pregnant or breastfeeding, follow the "green list" of safety precautions: lidocaine and hydrocortisone are acceptable in short courses and minimal doses; vasoconstrictors should only be used as prescribed by a doctor. At the same time, be sure to maintain a healthy bowel habit (macrogol, water, fiber). [49]

Table 8. Quick decision map

If	That (the first step)	Further
Pain/itching of external form	Lidocaine briefly + baths	For swelling - hydrocortisone briefly; then barrier care [50]
Blood without pain	Assistance with stool + examination	According to indications - office methods; ointments only for skin [51]
"Lump", sharp pain	Discuss excision (≤72 h)	In the conservative way - lidocaine, baths, stool [52]
Pregnancy/lactation	Lidocaine, hydrocortisone - in short	Avoid phenylephrine unless prescribed; macrogol daily [53]

Results: What really works and why

Hemorrhoid ointments are a symptom-control tool: anesthetics reduce pain and itching, steroids reduce swelling and inflammation, and barrier creams protect the skin. They work best as part of a combination plan: short courses of topical ointments + soft stools (macrogol as a base) + good toilet hygiene +, if indicated, office or surgical procedures. This is precisely the approach recommended by current clinical guidelines. [54]

The choice of ointment depends on the scenario: external application – skin and pain (topics in the foreground); internal nodes with blood – diagnosis and procedures; thrombosis of an external node – taking into account the 48-72 hour "window." Without established bowel movements, any tubes provide a temporary effect. [55]

During pregnancy and breastfeeding, lidocaine and hydrocortisone are permitted in short courses and minimal doses; vasoconstrictor components are only permitted by prescription. This is the official position of national services. [56]

If there are "red flags" (heavy bleeding, weakness, irreversible prolapse, rapidly increasing pain), ointments are not a substitute for in-person care. In such situations, a safety protocol is more important than any over-the-counter medication. [57]