Botulinum toxin A in anal fissures: a modified technique

Anal fissures are common and painful. Botulinum toxin A (BTXA) is considered to be the most potent non-surgical treatment; however, no attention has been paid to associated hyperhidrosis.

To compare traditional BTXA treatment of muscular spasticity in anal fissures with combined treatment of spasticity and focal hyperhidrosis of the anal fold and perianal skin.

Outpatient department of a dermatological hospital.

Ten patients with chronic anal fissures (of more than 6 months duration who failed to respond to conservative treatment and who had refused surgery) associated with focal hyperhidrosis as assessed by Minor's sweat test were investigated in an open, two-armed trial. Intramuscular injections of 20-25 U BTXA (Botox) were performed in group A (n = 5). In group B (n = 5) those injections were combined with intracutaneous injection of 30-50 U BTXA to treat focal hyperhidrosis. Mean follow-up was 5 months.

Five of five patients in group B but only two of five patients in group A experienced a complete remission despite the fact that relief of pain was evident in eight of 10 patients within 2 weeks. Patient satisfaction with treatment was high but slightly better in group B.

This open trial suggests that combined therapy of both muscular spasticity and focal hyperhidrosis may provide better results than intramuscular injections alone in anal fissure therapy with BTXA.