An acute fissure is a fresh tear in the anal lining, usually under six weeks old. It’s painful, bleeds sometimes, and in a good number of cases heals on its own with the right diet and topical treatment. A chronic fissure has been there longer. The skin’s tried to heal, failed, and now there’s scar tissue, a skin tag at the edge, and an internal sphincter locked in spasm. That spasm cuts off blood supply to the wound base and is exactly why it won’t close. Same tear, completely different biology, different treatment pathway.

According to Dr. Rajeev Premnath, a leading piles specialist in Bangalore, The mistake most patients make is waiting too long. What starts as an acute fissure that could heal in weeks becomes a chronic one that needs a procedure because nobody treated it early enough.

Acute fissures respond well to conservative measures. Treatment focuses on softening stool consistency and reducing internal sphincter tone to restore adequate blood supply to the wound base.

• Dietary changes first: High fibre food and eight to ten glasses of water daily keeps stools soft and reduces the straining that caused the tear in the first place. Most patients don’t realise this alone changes outcomes significantly.
• Sitz baths are unglamorous but genuinely useful. Fifteen minutes in warm water after a bowel movement reduces sphincter tone, eases pain, and keeps the area clean. Patients ignore this recommendation constantly, and it matters more than they think.
• Topical nitrates: GTN ointment relaxes the internal sphincter and improves blood flow to the wound base. Works in roughly 50 to 70% of acute cases, though headaches are a common side effect that stops some patients from continuing it.
• Diltiazem cream: Calcium channel blocker applied locally with similar healing rates to GTN but fewer headaches, so it’s often the first choice now when topical therapy is being considered for an acute tear.

Most acute cases resolve within four to six weeks if treatment starts early and stays consistent. Waiting past that point without improvement means reassessment, not more of the same ointment. Get a proper evaluation for fissure treatment before a short-term problem turns chronic.

By the time a fissure is chronic, topical therapy alone rarely works. Elevated sphincter tone, poor wound vascularity, and scar tissue at the edges all need to be addressed directly.

• Botox injection: Botulinum toxin injected into the internal sphincter relaxes it for two to three months, which is sometimes enough for the fissure to finally close without surgery. Works better in patients with no previous operations in the area.
• LIS: Lateral internal sphincterotomy divides a small portion of the internal sphincter under anaesthesia, drops the elevated tone, and lets blood supply reach the wound base properly. Heals over 90% of chronic fissures. Minor risk of incontinence to flatus is why patient selection still matters.
• Laser fissurectomy: The scarred base gets removed under laser, leaving clean tissue edges that can actually close. Less invasive than LIS, though recurrence rates run slightly higher in cases with significant fibrosis.
• Advancement flap is reserved for situations where LIS isn’t appropriate because sphincter function is already compromised, or where a previous LIS has failed. Not a common first choice, but it’s an option when everything else hasn’t worked.

The longer a chronic fissure goes without proper treatment, the more distorted the local anatomy becomes. For a detailed look at when surgery becomes the only realistic option, our previous blog on fissure surgery covers the full decision-making process.

Dr. Rajeev Premnath holds MBBS, MS (Gen Surg.), FRCS (Glasg), FEBS, FICS, FACS, FIAGES, FMAS, and a Diploma in Laparoscopy from France. With 20+ years at Ramakrishna Super Speciality Hospital, he manages acute and chronic fissures across the full treatment spectrum, from dietary advice to laser and LIS, matching the approach to the actual stage rather than defaulting to surgery when it isn’t needed.

Patients with both acute and chronic fissures achieve lasting relief with the right treatment at the right stage. Outcomes are built on accurate diagnosis, appropriate intervention, and proper post-procedure care throughout recovery.

Disclaimer:

This blog is for educational and informational purposes only and should not be considered professional advice.