External hemorrhoids: symptoms and relief

External hemorrhoids are swollen cushions under the skin at the anal opening. They hurt, itch, and make sitting miserable in a way internal hemorrhoids usually do not. Internal ones sit higher, where the lining barely feels pain, so they tend to announce themselves with blood. External ones are covered by ordinary skin. You can feel them.

A flare is often short. For many people the swelling and ache ease within a few days ³. This page is about that outside lump: what it feels like, how to calm the skin, how to stay clean without making the itch worse, what a leftover skin tag is, and when a surgeon talks about cutting one out. The map of both types is on hemorrhoids. How long each type of flare lasts is broken down in how long hemorrhoids last.

If the lump showed up over a few hours and feels like a hard marble, read thrombosed hemorrhoid before you finish this page. That is a clot, and the first two or three days are treated on a different clock. Do not squeeze or lance it at home. Why popping a hemorrhoid backfires explains the risks.

Why external hemorrhoids hurt

Doctors draw the line at the dentate line, inside the anal canal. External hemorrhoids are below it. A review of hemorrhoid anatomy describes them as covered by anoderm, which is skin, with somatic nerves that supply the perianal skin and produce pain ². The ASCRS patient page on hemorrhoids puts it simply: external hemorrhoids are covered by skin that is very sensitive to touch, pain, stretch, and temperature ¹.

NIDDK lists the symptoms people actually notice: anal itching, one or more hard tender lumps near the anus, and an ache or pain that is worse when you sit. Too much straining, rubbing, or cleaning makes those symptoms worse ³. MedlinePlus adds a practical problem: external hemorrhoids can make it hard to get clean after a bowel movement ⁵.

The symptom list for both types, including what is more likely internal, is on hemorrhoid symptoms.

Itching and sore skin

Itch has more causes than the hemorrhoid itself. A review of pruritus ani, the medical name for an itchy anus, found that anorectal conditions are the main group of causes, and that the usual plan is to remove irritants, stop the scratch cycle, and then treat what is left. The evidence behind a lot of the itch treatments is weak ⁶.

What you can change this week is the irritant list. Pat dry instead of rubbing. The NHS page on piles says to keep the area clean and dry and to pat rather than rub ¹². Skip scented or colored toilet paper if it stings. If wet wipes seemed to help and then the rash would not quit, stop them. A series of six children with a stubborn rash around the anus and face traced it to methylisothiazolinone, a preservative in the wipes. The rash cleared when the wipes stopped. The authors said a rash in those areas plus wet-wipe use should raise the question of an allergy to that preservative ¹⁵. A plain rinse is often kinder than another medicated wipe.

If itch is what keeps you up, the bedtime steps are on why hemorrhoids itch more at night. For the position itself, see the best sleeping position for hemorrhoids.

Hydrocortisone is the steroid most often sold for this itch. The NHS instructions for hydrocortisone for piles say to use it morning, at night, and after a bowel movement, and not for more than 7 days. If it has not helped by then, or the symptoms bounce back as soon as you stop, see a doctor ⁷. NIDDK gives the same one-week window for over-the-counter creams, ointments, and suppositories, and says to stop sooner if you get a rash or very dry skin ⁸. Follow the label. A longer course is a doctor’s decision, not a refill you decide on your own. How creams, ointments, and pads differ is on over-the-counter hemorrhoid treatment.

Swelling, and warm water versus cold

Two different sensations get mixed together. Swelling and throbbing feel better to a lot of people with something cool. The ache from a tight muscle feels better with warmth.

In a pressure study of hot and cold water, resting anal pressure fell after the anus was immersed in water at 40 degrees Celsius. Water at 5 degrees Celsius, which is ice-water cold, and water at room temperature did not change the pressure. After a 5-minute warm immersion, the drop lasted about 15 minutes in people without anorectal disease and about 30 minutes in people who already had anorectal pain ¹⁰. A separate study of warm baths found that internal sphincter activity dropped in the bath and the relief of pain tracked that drop. Higher bath temperatures produced a bigger drop and a longer effect. The baths in that study ran up to 50 degrees Celsius, which is hot enough to burn ¹¹.

A review of sitz bath evidence found very little trial proof that soaks treat anorectal disease, and it recorded burns among the complications ⁹. So use a soak for comfort. Fill it with water that feels warmly comfortable on your wrist, not water you have to pull your hand out of. NIDDK suggests a sitz bath several times a day for pain ⁸. The timings and the setup are on how to take a sitz bath.

The NHS also lists an ice pack wrapped in a towel for discomfort ¹². Cold did not relax the sphincter in the pressure study, so do not expect it to do the same job as a warm soak. It is a reasonable short numbing step for throbbing swelling. Which one to use, and for how long, is compared on ice or heat for hemorrhoids.

Getting clean without starting the itch again

Stool left on sore skin is an irritant, and hard wiping is another. The goal is clean and dry, with as little friction as you can manage.

After a bowel movement, rinse if you can, then pat. A warm shower aimed with a handheld sprayer works. So does a squeeze bottle. Then a soft towel, a pat, and air if you have a private minute. The NHS line is the same: clean, dry, pat rather than rub ¹².

Cooling pads are the drugstore version of that pat. Buyers of medicated cooling pads often fold one and leave it against the skin for a short cool compress, and they mention that the pads can stick together in the tub. An ointment is the option when the skin is raw and you want something that stays put. Buyers of a standard hemorrhoid ointment often say it stays where they put it. Itch relief is less consistent than the soothing effect. The comparisons are on the best hemorrhoid wipes page and the best hemorrhoid ointments page.

Pain that is still sharp after a plain ointment is the situation a numbing ointment is for. That choice lives on the ointments page. Do not layer a numbing cream and a steroid forever. The one-week steroid limit still applies ^7,8.

Softer stools reduce the scraping that starts the next flare. A 2006 meta-analysis of seven fiber trials found fiber lowered the chance that hemorrhoid symptoms would fail to improve, and cut the risk of bleeding by about half. Pain and itching looked better in some trials, but the pooled results were too wide to be sure ¹³. Fiber is still the right daily habit, because straining and hard stools are on the NIDDK cause list ³. Treat the skin for the week. Treat the stool for the month.

Skin tags

A skin tag is extra skin at the opening. The ASCRS patient page describes the usual story: a clot stretches the skin, the body absorbs the clot, and the stretched skin stays. Some people have tags with no clot they can remember. Tags are painless. They bother people because they trap moisture and make it harder to wipe clean, or because of how they look. Most of the time the treatment is an explanation and nothing else. Surgical removal is occasionally considered ¹.

NIDDK lists skin tags as something a doctor looks for on exam, and as a complication left behind when a clot in an external hemorrhoid dissolves ^4,14. Tell your doctor if a tag is the reason you cannot get clean. That is a different conversation from a painful flare. How to tell a tag from a hemorrhoid, the link with Crohn’s disease, and what removal involves are in anal skin tags.

Clots, in brief

A clot in an external hemorrhoid is a hard, very tender lump under the skin. NIDDK lists blood clots in an external hemorrhoid as a complication, along with infection of a sore on the outside and, less often, a strangulated internal hemorrhoid ⁴. MedlinePlus notes that hemorrhoids are often not very painful until a clot forms ⁵.

The outside lump without a clot is this page. The clot, including why the first 72 hours matter and how the pain usually eases, is the thrombosed hemorrhoid page. If you cannot sit, go there now and use the urgent-care section.

When excision is considered

External hemorrhoids that are not clotted are generally managed with diet and topical treatment. The ASCRS patient page says they are only occasionally removed, and that removal cannot be done as a simple office nip. Hemorrhoidectomy, cutting the tissue out in an operation, may be considered for symptomatic large external hemorrhoids, for combined internal and external hemorrhoids, and for grade 3 or 4 prolapse. Fewer than 10 percent of people evaluated for symptomatic hemorrhoids need surgery ¹.

NIDDK describes hemorrhoidectomy as the operation for large external hemorrhoids and for prolapsing internal hemorrhoids that have not responded to other treatment. It is done with anesthesia, in an outpatient center or a hospital ⁸.

A reasonable sequence is the week of home care first: warm soaks, gentle cleaning, fiber, and a short course of cream. If the lump is still painful, still in the way of cleaning, or back every week, that is the visit where removal gets discussed. A tag that is only a cosmetic concern is usually left. A tag or a hemorrhoid that stops you getting clean is the one to mention out loud.

Sharp, tearing pain that hits during the bowel movement and then throbs for a while afterward is the pattern of an anal fissure, a small tear. An external hemorrhoid is more of a lump you can feel, with an ache that shows up when you sit. The two are compared on the fissure page linked above. ASCRS notes that an exam has to sort hemorrhoid symptoms from other disease, including fissures and, rarely, cancer ¹.

When to get the flare checked

Call if a week of home care has not helped, or if you see rectal bleeding ³. Pain is the symptom people notice first with an external hemorrhoid. New blood still needs an explanation. Screening for colon cancer is recommended from age 45 for adults at average risk ¹⁶. The visit itself is described on when to see a doctor for hemorrhoids.

Same-day care is for pain you cannot sit with, heavy bleeding, or bleeding with fever. The NHS directs people to emergency care for bleeding that does not stop, a large amount of blood, large clots, or severe pain ¹².

NHS advice on pain pills: skip ibuprofen if the hemorrhoids are bleeding, and skip codeine because it causes constipation ¹². Acetaminophen is the usual alternative for the ache while the soak and the fiber do their work. If you are pregnant, check any medicated cream with your obstetric clinician before you use it. The one-week steroid limit is a good default even then ⁷.