OBJECTIVE:
The  article presents a full  review of hemorrhoids treatment with  reference to  general practice setting.
the  estimation is  that 50% of the people suffer from  hemorrhoids by the age of 50 .
patients often regard   the condition as  a single simple disease, this is not so.

Hemorrhoids   responding when  using  self-treatment are usually very  mild and only  self-limiting and normal hemorrhoids   heal without medication.
There are several  non pharmacological methodes  to deal with  hemorrhoids.
ther is an  encouragment  to sit in a warm bath of water or sitz baths for 15 minutes,aprox  three to four times each  day, and to cleanse the area with mild, unscented soap and water after using the toilet.
in  case of a Serious hemorrhoids condition it may require rubber band ligation, cryotherapy,  hemorrhoidectomy,  infrared photocoagulation,sclerotherapy, bipolar diathermy or laser therapy.most important in tretment of hemorrhoids is the aspect of prevention.
Take the  following measures in order to help prevent hemorrhoids and  also to help the shrinking of less severe cases:

• Not postponing the urge to defecate;helps to Avoid constipation 
• Eating a balanced, high-fiber diet;
• to drink plenty of water, fluids;
• also Exercise; and
• Avoid excessive pressure and straining during defecation.
  

There are several  over-the-counter (OTC) pharmacologic agents for the management of  hemorrhoids symptoms
including  , protectants, local anesthetics,astringents, hydrocortisone and antipruritics, keratolytics,

Most  of the hemorrhoids symptoms should resolve within afew days to a week  of treatment with the available  OTC products.
in case that the symptoms are not resolved, a physician should be consulted because of a threat of other, more serious, conditions.

The FDA has divided these products into those that can be inserted intrarectally for internal hemorrhoids and those intended for external use only. Astringents, protectants and vasoconstrictors can be used for internal hemorrhoids . No ingredients are approved by the FDA for intrarectal use to alleviate pain, soreness or burning.

Astringents: Astringents coagulate the proteins in surface skin cells, which results in decreased cellular volume and a leaves a thin layer protecting underlying tissue. In addition, these agents decrease mucous and other secretions in order to decrease inflammation and irritation of the area.
Astringents also provide relief of burning and itching but not of pain.
Calamine and zinc oxide (in concentrations of 5%–25%) are recommended for both internal and external use up to six times a day, whereas witch hazel, also known as hamamelis water (concentration of 10%–50%), is recommended for external use, providing temporary relief of itching, discomfort, irritation and burning.⁴

Protectants: Protectants form a physical barrier over the skin and mucous membranes, thereby decreasing inflammation and preventing water loss from the stratum corneum.
When protectants such as absorbents, adsorbents, demulcents and emollients are included in an OTC formulation, they should make up at least 50% of the dosage unit.
Recommended protectants include: aluminum hydroxide gel, cocoa butter, glycerin in aqueous solution, hard fat, kaolin, lanolin, mineral oil, white petrolatum, petrolatum and topical starch.
All of these are approved for intrarectal and external use with the exception of glycerin, which is reserved for external use only.
Calamine, zinc oxide, cod liver oil and shark liver oil are recommended only when combined with one to three other protectants listed above. Side effects are minimal but may include hypersensitivities.

Vasoconstrictors: Vasoconstrictors stimulate the alpha-adrenergic receptors in the vasculature and promote constriction of the blood vessels.

One sequela of hemorrhoids is the pooling of blood in dilated veins. The vasoconstrictors may be used to reduce swelling of these engorged blood vessels.
Vasoconstrictors relieve itching, discomfort and irritation due to a slight anesthetic effect.

These products, ephedrine sulfate and phenylephrine hydrochloride, are chemically similar to naturally occurring catecholamines (i.e., epinephrine and norepinephrine).

Serious adverse effects of vasoconstrictors include elevation of blood pressure, cardiac arrhythmias, nervousness, tremor, insomnia, and aggravation of symptoms of hyperthyroidism.
Vasoconstrictors should be avoided in patients with diabetes, hyperthyroidism and hypertension, as well as patients who experience difficulty urinating due to enlarged prostate or those patients taking monoamine oxidase inhibitors or tricyclic antidepressants.

Local anesthetics: Anesthetics relieve the sensations of pain, burning, itching, discomfort and irritation by reversibly blocking nerve conduction.
These products should be used externally on the perianal area due to the sensory nerve endings saturated in this area.
If absorbed by the rectal mucosa, potential toxic effects can occur systemically. Allergic reactions can also occur, including burning and itching, which can aggravate the already inflamed tissues.
Active ingredients often found in local anesthetics include benzocaine, benzyl alcohol, dibucaine, cyclonine, lidocaine, pramoxine and tetracaine.

Keratolytics: Keratolytics cause desquamation and sloughing of the epidermal surface of cells in the perianal area.
This turnover and debridement of the epidermis allows exposure of inflamed tissues to therapeutic agents. Keratolytics are also useful in reducing itching and discomfort.
Keratolytics, aluminum chlorhydroxy allantoinate (alcloxa) and resorcinol are for use in external hemorrhoids only.
Pharmacists must warn against using products containing resorcinol near open wounds around the perianal area.

Antipruritics: Formerly classified as counterirritants, antipruritics have now been redesignated by the FDA as "analgesics, anesthetics, and antipruritics."
These products stimulate the cold receptors and depress cutaneous sensory receptors in the perianal area, resulting in sensations that distract from the annoying symptoms of hemorrhoids.
Analgesics, anesthetics, and antipruritics include menthol, juniper tar, and camphor; however, menthol, camphor and turpentine oil are not considered safe or effective.

Hydrocortisone: Hydrocortisone is safe and effective for relief of anorectal itching and swelling; however, OTC products containing hydrocortisone are not recommended by the FDA for anorectal use.
Anorectal products containing hydrocortisone must be obtained by prescription.
Hydrocortisone has anti-inflammatory, lysosomal membrane stabilization, antimitotic and vasoconstrictive properties that may be beneficial in relieving hemorrhoids.
Like other ingredients, hydrocortisone can cause local irritation and allergic reactions that would interfere with the healing of perianal tissue.