Botulinum toxin A in anal fissures: a modified technique.

BACKGROUND: 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.

AIM: 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.

SETTING: Outpatient department of a dermatological hospital.

PATIENTS AND METHODS: 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.

RESULTS: 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.

CONCLUSIONS: 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.