Topically applied cannabidiol (CBD) might provide the best balance of efficacy and safety for the treatment of anal fissures, according to a case series. Tested because of its vasoactive properties, topical CBD significantly improved symptoms in all patients in the series.
Based on the substantial symptomatic improvement and accelerated healing, “the relative absence of side effects could position CBD as first-line therapy in the medical management of both acute and chronic anal fissures,” said the two investigators, Nikolas A. Deal-Laroda, MBBS, and E. Marcus Cooper, MD, of the University of West Indies School of Clinical Medicine and Research, in Nassau, Bahamas.
All four patients in the study (two women and two men) had fissures in the posterior midline and had previously tried topical preparations without improvement before seeking medical attention. The topical CBD (Global Advanced Botanicals) was applied along the anal verge at a dose of 1.724 mg/g three times per day. Patients were advised to maintain a high-fiber diet and to take a fiber supplement. Use of nonprescription anti-inflammatory drugs or other analgesics was permitted.
Prior to the use of CBD, one of the four patients had persistent symptoms for six months, but the majority had symptoms from one to two weeks. The women were 30 and 54 years of age, and the men were 50 and 65 years.
Improvement in symptoms was achieved by day 4 of initiating therapy in two of the patients. In another, symptoms improved by day 8. The longest time to response was 12 days. The degree of symptom reduction was substantial when measured by a visual analog scale in all those treated, according to the researchers, who presented their findings at the 2020 virtual meeting of the American College of Gastroenterology (abstract P0555).
“We believe that topical CBD will become the primary options for the medical management of anal fissures because of its efficacy and the absence of side effects,” said Cooper, who also is a principal of GastroCare Bahamas, a private practice in Nassau.
CBD induces endothelium and nitric oxide–dependent vasodilation, according to Cooper, the same mechanism by which many alternative therapies for anal fissures, such as calcium channel blockers and nitrates, are thought to relieve symptoms. Cooper said evidence suggests that the improvement in blood flow reduces local ischemia and promotes healing, although his study lacked controls with which to compare resolution of the fissures.
“Cannabinoids also have potent anti-inflammatory effects mediated by induction of apoptosis, inhibition of cell proliferation and suppression of cytokine production,” Cooper said.
Although Cooper said he believes this series is the first to show a benefit for CBD in the treatment of anal fissures, the consistency of the effect was compelling.
A trial of CBD should now be considered in more patients with chronic fissures who do not respond or are unable to tolerate standard medical treatments, he added.
However, Waqar Qureshi, MD, the chief of endoscopy at Baylor College of Medicine, in Houston, and the author of a recent article on managing anal fissures (Am J Gastroenterol 2020;115[3]:315-316), said the latest report does not support widespread use of topical CBD for the treatment of anal fissures despite the apparent safety of the compound.
“Many anal fissures heal spontaneously, especially when you add fiber to the diet,” Qureshi said. A series of four patients “is not meaningful.” He not only urged a larger series, but one with a placebo control.
However, Evan Goldstein, DO, the founder of Bespoke Surgical, in New York City, said he has used CBD in his patients with anal fissures because of its ability to reduce inflammation and pressure on the muscles in the anatomic area. “The lowering of localized muscle pressure remedies the tear for complete healing and then sets the stage for future anal play, if so desired,” Goldstein said.
—Ted Bosworth
This article is from the April 2021 print issue.