My diltiazem cream finally arrived today. However, there are no instructions or anything. It's basically a little tub with a "Diltiazem 2%" label and that's it. No instructions at all other than apply two to three times daily. My GP didn't give me any instructions either. What kind of amount do I use? Does it go externally around the anus or do I try to get as much as possible inside?

Use a pea sized 1cm amount (but confirm this with your doctor). Apply just slightly inside the anus, it will be absorbed well. Make sure you wear gloves or a finger cot. Dry the area thoroughly beforehand with a hairdryer (on cool) or air dry. Apply before a BM if you like since that can help loosen things up beforehand, and then reapply afterwards. Hoping you heal soon!

Thank you!

Out of curiosity how long does it usually take for the cream to kick in? I've got full on burning and spasms again. The two BMs this morning weren't too painful but the fissure started burning within ten seconds and then improved as I wiped (dabbed with WaterWipes, they're expensive but great) the stool away. I was ok until around an hour after the second BM. I usually have at least three BMs per day and my high Movicol intake at the moment to keep things very soft doesn't exactly lower the number of BMs.

It should be effective pretty quickly. I usually feel the muscle loosening up in 15-20 minutes when I apply nifedipine. Movicol is polyethylene glycol right? That caused a lot of burning for me so I stopped taking it and I rely on lactulose and stool softeners instead. Very runny BMs are irritating to a fissure, so you want to make sure that doesn't happen. Also, any remaining stool also causes irritation. I make sure to wash with water and (TMI) use my finger to clean just inside the opening to remove any residue.

By the way, several people on this board have mentioned that diltiazem gave them rash and irritation so watch for that. In which case you would need to switch to nifedipine ( works the same way)

Thank you for your replies.
Lactulose is unfortunately the reason I'm in agony... I read some negative things about Movicol, or rather PEG3350, and decided to try lactulose instead. I used the max amount recommended on the bottle and it took less than a week to get constipated and for the AF to re-surface after three years of pretty much no problems at at. I've taken a daily sachet of Movicol and eaten my five a day and the most trouble I had was one minor incident in 2015 and one in 2016. Minor incident = one or two slightly uncomfortable BMs with no issues at all after. I'm back on Movicol and my BMs are soft now but I think I need to go down to two sachets a day rather than three for time time being.

I've probably not used enough diltiazem then as I've not noticed anything at all after I've applied it. Then again, I started using it this morning.
The burning and spasms don't last as long as they did a week ago and I guess that's progress. I was in agony for around two hours this morning. It weirdly enough seems like subsequent BMs after the first two don't result in as much agony. I had another BM around four hours ago and nothing bar some minor burning after that.

Less pain for later BMs may be because the muscles have been sort of stretched out by previous BMs. Sorry to hear the lactulose was the cause of your problems. It just shows how unique each person's case can be.

I suspect that uniqueness is what makes it challenging to treat at times.
I actually do a bit better today which is nice. I had a fair amount of pain from around two hours after the second BM of the day but the pain subsided in around an hour and a half. I'm not pain free now but it's possible to sit down without it being particularly uncomfortable. I used the cream again this morning and will keep using it for six weeks or until it runs out whichever happens first. The fissure is still raw and easy to feel but I hope it'll start to heal in the next week or two.

Great! I experienced the same ease with sitting when I started using nitroglycerin. I plateaued after a while so switched to nifedipine.