1 Gastro-intestinal system
1.7 Local preparations for anal and rectal disorders
1.7.1 Soothing anal and rectal preparations
1.7.2 Compound anal and rectal preparations with corticosteroids 1.7.3 Rectal sclerosants
1.7.4 Management of anal fissures
In children with perianal soreness or pruritus ani, good toilet hygiene is essential;
the use of alcohol-free ‘wet-wipes’ after each bowel motion, regular bathing and the avoidance of local irritants such as bath additives is recommended.
Excoriated skin is best treated with a protective barrier emollient (section 13.2.2); in children over 1 month,hydrocortisone ointment or cream (section 13.4) or a compound rectal preparation (section 1.7.2) may be used for a short period of time, up to a maximum of 7 days.
Pruritus ani caused by threadworm infection requires treatment with an anthel-mintic (section 5.5.1). Topical application ofwhite soft paraffin or other bland emollient (section 13.2.1) may reduce anal irritation caused by threadworms.
Perianal erythema caused by streptococcal infection should be treated initially with an oral antibacterial such as phenoxymethylpenicillin (section 5.1.1.1) or erythromycin (section 5.1.5), while awaiting results of culture and sensitivity testing.
Perianal candidiasis (thrush) requires treatment with a topical antifungal prepara-tion (secprepara-tion 13.10.2). For treatment of vulvovaginal candidiasis, see secprepara-tion 7.2.2.
Proctitis associated with inflammatory bowel disease in children is treated with corticosteroids and aminosalicylates (section 1.5).
For the management of anal fissures, see section section 1.7.4.
BNFC 2009 1.7 Local preparations for anal and rectal disorders
87
1Gastro-intestinalsystem
1.7.1
Soothing anal and rectal preparationsHaemorrhoids in children are rare, but may occur in infants with portal hyper-tension. Soothing rectal preparations containing mild astringents such as bismuth subgallate, zinc oxide, and hammamelis may provide symptomatic relief, but proprietary preparations which also contain lubricants, vasoconstrictors, or mild antiseptics may cause further perianal irritation.
Local anaesthetics may be used to relieve pain in children with anal fissures or pruritus ani, but local anaesthetics are absorbed through the rectal mucosa and may cause sensitisation of the anal skin. Excessive use of local anaesthetics may result in systemic effects, see section 15.2. Preparations containing local anaes-thetics should be used for no longer than 2–3 days.
Lidocaine (lignocaine) ointment (section 15.2) may be applied before defaecation to relieve pain associated with anal fissure, but local anaesthetics can cause stinging initially and this may aggravate the child’s fear of pain.
Other local anaesthetics such as tetracaine (amethocaine), cinchocaine (dibu-caine), and pramocaine (pramoxine) may be included in rectal preparations, but these are more irritant than lidocaine.
Corticosteroids are often combined with local anaesthetics and soothing agents in topical preparations for haemorrhoids and proctitis. Topical preparations containing corticosteroids (section 1.7.2) should not be used long-term or if infection (such as herpes simplex) is present. For further information on the use of topical corticosteroids, see section 13.4.
1.7.2
Compound anal and rectal preparations with corticosteroidsAnugesic-HCc(Pfizer)A
Cream, benzyl benzoate 1.2%, bismuth oxide 0.875%, hydrocortisone acetate 0.5%, Peru balsam 1.85%, pramocaine hydrochloride 1%, zinc oxide 12.35%. Net price 30 g (with rectal nozzle) = £3.71 Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsapply night and morning and after a bowel movement; do not use for longer than 7 days
Suppositories, buff, benzyl benzoate 33 mg, bis-muth oxide 24 mg, bisbis-muth subgallate 59 mg, hydrocortisone acetate 5 mg, Peru balsam 49 mg, pramocaine hydrochloride 27 mg, zinc oxide 296 mg, net price 12 = £2.69
Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsinsert 1 suppository night and morning and after a bowel movement; do not use for longer than 7 days
Anusol-HCc(McNeil)A
Ointment, benzyl benzoate 1.25%, bismuth oxide 0.875%, bismuth subgallate 2.25%, hydrocortisone acetate 0.25%, Peru balsam 1.875%, zinc oxide 10.75%. Net price 30 g (with rectal nozzle) = £3.50 Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsapply night and morning and after a bowel movement; do not use for longer than 7 days
Suppositories, benzyl benzoate 33 mg, bismuth oxide 24 mg, bismuth subgallate 59 mg,
hydro-cortisone acetate 10 mg, Peru balsam 49 mg, zinc oxide 296 mg. Net price 12 = £2.46
Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsinsert 1 suppository night and morning and after a bowel movement; do not use for longer than 7 days
Perinalc(Dermal)
Spray application, hydrocortisone 0.2%, lidocaine hydrochloride 1%. Net price 30-mL pack = £6.39 Dose
Haemorrhoids, pruritus ani . By rectum
Child 2–18 yearsspray once over the affected area up to 3 times daily; do not use for longer than 7 days without medical advice (child under 14 years, on medical advice only)
Proctofoam HCc(Meda)A
Foamin aerosol pack, hydrocortisone acetate 1%, pramocaine hydrochloride 1%. Net price 21.2-g pack (approx. 40 applications) with applicator =
£5.06 Dose
Pain and irritation associated with local, non-infected anal or perianal conditions
. By rectum
Child 12–18 years1 applicatorful (4–6 mg hydro-cortisone acetate, 4–6 mg pramocaine hydrochloride) by rectum 2–3 times daily and after a bowel movement (max. 4 times daily); do not use for longer than 7 days
88
1.7.1 Soothing anal and rectal preparations BNFC 20091Gastro-intestinalsystem
Proctosedylc(Aventis Pharma)A
Ointment, cinchocaine (dibucaine) hydrochloride 0.5%, hydrocortisone 0.5%. Net price 30 g = £9.40 (with cannula)
Dose
Haemorrhoids, pruritus ani . By rectum
Child 1 month–18 yearsapply morning and night and after a bowel movement, externally or by rectum; do not use for longer than 7 days
Suppositories, cinchocaine (dibucaine) hydro-chloride 5 mg, hydrocortisone 5 mg. Net price 12 =
£4.24 Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsinsert 1 suppository night and morning and after a bowel movement; do not use for longer than 7 days
Scheriproctc(Valeant)A
Ointment, cinchocaine (dibucaine) hydrochloride 0.5%, prednisolone hexanoate 0.19%. Net price 30 g = £3.00
Dose
Haemorrhoids, pruritus ani . By rectum
Child 1 month–18 yearsapply twice daily for 5–7 days (3–4 times daily on 1st day if necessary), then once daily for a few days after symptoms have cleared
Suppositories, cinchocaine (dibucaine) hydro-chloride 1 mg, prednisolone hexanoate 1.3 mg. Net price 12 = £1.41
Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsinsert 1 suppository daily after a bowel movement, for 5–7 days (in severe cases initially 2–3 times daily)
Ultraproctc(Meadow)A
Ointment, cinchocaine (dibucaine) hydrochloride 0.5%, fluocortolone caproate 0.095%, fluocorto-lone pivalate 0.092%, net price 30 g (with rectal nozzle) = £4.57
Dose
Haemorrhoids, pruritus ani
Child 1 month–18 yearsapply twice daily for 5–7 days (3–4 times daily on 1st day if necessary), then once daily for a few days after symptoms have cleared
Suppositories, cinchocaine (dibucaine) hydro-chloride 1 mg, fluocortolone caproate 630 micr-ograms, fluocortolone pivalate 610 micrmicr-ograms, net price 12 = £2.15
Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsinsert 1 suppository daily after a bowel movement, for 5–7 days (in severe cases initially 2–3 times daily) then 1 suppository every other day for 1 week
Uniroid-HCc(Chemidex)A
Ointment, cinchocaine (dibucaine) hydrochloride 0.5%, hydrocortisone 0.5%. Net price 30 g (with applicator) = £4.23
Dose
Haemorrhoids, pruritus ani . By rectum
Child 1 month–18 yearsapply twice daily and after a bowel movement, externally or by rectum; do not use for longer than 7 days (child under 12 years, on medical advice only)
Suppositories, cinchocaine (dibucaine) hydro-chloride 5 mg, hydrocortisone 5 mg. Net price 12 =
£1.91 Dose
Haemorrhoids, pruritus ani . By rectum
Child 12–18 yearsinsert 1 suppository twice daily and after a bowel movement; do not use for longer than 7 days
Xyloproctc(AstraZeneca)A
Ointment(water-miscible), aluminium acetate 3.5%, hydrocortisone acetate 0.275%, lidocaine 5%, zinc oxide 18%, net price 20 g (with applicator)
= £2.26 Dose
Haemorrhoids, pruritus ani . By rectum
Child 1 month–18 yearsapply several times daily;
short-term use only
1.7.3
Rectal sclerosantsClassification not used in BNF for Children.
1.7.4
Management of anal fissuresThe management of anal fissures includes stool softening (section 1.6) and the short-term use of a topical preparation containing a local anaesthetic (section 1.7.1). If these measures are inadequate, children with chronic anal fissures should be referred for specialist treatment in hospital. Topicalglyceryl trinitrate, 0.05%
or 0.1% ointment, may be used in children to relax the anal sphincter, relieve pain and aid healing of anal fissures. Excessive application of topical nitrates causes side-effects such as headache, flushing, dizziness, and postural hypotension.
Before considering surgery,diltiazem 2% ointment may be used in children with chronic anal fissures resistant to topical nitrates.
BNFC 2009 1.7.4 Management of anal fissures
89
1Gastro-intestinalsystem
Ointments containing glyceryl trinitrate in a range of strengths or diltiazem 2%
are available as manufactured specials (see Special-order Manufacturers, p. 943).