Topical Pain Treatments

Why Topical Treatments?

Topical pain treatments are applied directly to the skin over the painful area. They offer several advantages over oral medications: they deliver medication directly to the site of pain, generally have fewer systemic side effects, and can be used alongside other treatments.¹

Topicals work best for localized pain—pain in a specific area rather than widespread pain. They're particularly useful for joint pain, muscle aches, and certain types of nerve pain.

Advantages of Topicals

• Targeted delivery to painful area
• Lower systemic absorption (fewer side effects)
• Can avoid GI side effects of oral medications
• Some available without prescription
• Easy to use as needed
• Can combine with other treatments

Types of Topical Treatments

Topical NSAIDs

Anti-inflammatory medications in cream, gel, or patch form:²

• Diclofenac gel (Voltaren) - Now OTC for arthritis pain
• Diclofenac patches - Prescription
• Diclofenac solution (Pennsaid) - For knee OA
• Ketoprofen - Available in some countries

What They Treat

• Osteoarthritis (especially knee and hand)
• Acute muscle strains and sprains
• Localized inflammatory pain

Effectiveness

• Good evidence for knee and hand osteoarthritis³
• Work best for joints close to surface
• Less effective for deep or widespread pain

Lidocaine

A local anesthetic that numbs the area:⁴

• Lidocaine patches (Lidoderm) - Prescription; 5% lidocaine
• OTC lidocaine products - Lower concentrations (4%)
• Lidocaine cream/gel - Various strengths

What They Treat

• Postherpetic neuralgia (FDA-approved)
• Other localized nerve pain
• Muscle pain
• Some joint pain

Usage Tips

• Patches worn 12 hours on, 12 hours off
• Can cut patches to fit area
• Numbing effect felt within 30-60 minutes

Capsaicin

Derived from hot peppers; depletes substance P:⁵

• OTC creams - Low concentration (0.025-0.1%)
• Qutenza patch - High concentration (8%); prescription, applied in clinic

What They Treat

• Neuropathic pain (diabetic neuropathy, postherpetic neuralgia)
• Osteoarthritis
• Some musculoskeletal pain

Important Notes

• Causes burning sensation initially—this decreases with regular use
• Must be applied consistently (3-4 times daily) for weeks
• Wash hands thoroughly after applying
• Avoid eyes and mucous membranes

Counterirritants (Menthol, Camphor, Methyl Salicylate)

Create cooling or warming sensations that distract from pain:

• Products: Bengay, Icy Hot, Biofreeze, Tiger Balm
• Mechanism: Stimulate nerve endings, creating sensation that "competes" with pain
• Best for: Muscle aches, minor joint pain, temporary relief

Compounded Topicals

Custom-made by compounding pharmacies:

• Can combine multiple ingredients
• Common ingredients: ketamine, gabapentin, baclofen, amitriptyline
• Limited research evidence
• May be worth trying when other options fail
• Often not covered by insurance

How to Use Topical Treatments

General Guidelines

• Clean, dry skin - Apply to intact skin only
• Use appropriate amount - Follow package directions
• Don't cover - Unless directed (can increase absorption)
• Wash hands after - Unless treating hands
• Avoid heat - Can increase absorption and side effects

Application Tips

• Apply to area of pain and slightly beyond
• Gently rub in (don't massage vigorously)
• Allow to dry before covering with clothing
• Be consistent with scheduled applications

Side Effects

Common Side Effects

• Skin irritation - Redness, itching, burning at application site
• Capsaicin burning - Expected; diminishes with regular use
• Contact dermatitis - Allergic reaction possible

Systemic Effects (Usually Minimal)

• Some absorption does occur
• Topical NSAIDs may have some cardiovascular/GI risk with extensive use
• Generally much lower risk than oral medications

Effectiveness Considerations

Best Candidates

• Localized pain in specific area
• Pain in joints close to skin surface
• People who can't take oral medications
• Adjunct to other treatments

Limitations

• Less effective for deep structures
• Don't work for widespread pain
• May need frequent reapplication
• Effects often modest

Practical Recommendations

• Start with OTC options - Voltaren gel, lidocaine, capsaicin
• Give adequate trial - Several weeks for some (especially capsaicin)
• Try different types - Different mechanisms may work better for you
• Combine approaches - Can use with oral medications and other treatments
• Consider prescription if OTC fails - Lidocaine patches, compounded creams

References

1. Argoff CE. Topical analgesics in the management of acute and chronic pain. Mayo Clinic Proceedings. 2013;88(2):195-205.
2. Derry S, Conaghan P, Da Silva JAP, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews. 2016;4(4):CD007400.
3. Zeng C, Wei J, Persson MSM, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: a systematic review and network meta-analysis. British Journal of Sports Medicine. 2018;52(10):642-650.
4. Derry S, Wiffen PJ, Moore RA, Quinlan J. Topical lidocaine for neuropathic pain in adults. Cochrane Database of Systematic Reviews. 2014;(7):CD010958.
5. Derry S, Rice AS, Cole P, Tan T, Moore RA. Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews. 2017;1(1):CD007393.