Key Takeaways
- Topical treatments deliver pain relief directly to the affected area
- Generally have fewer systemic side effects than oral medications
- Various types work through different mechanisms
- Good option for localized pain, especially in older adults
Why Topical Treatments?
Topical pain medications are applied directly to the skin over painful areas. They can provide relief while minimizing the systemic side effects associated with oral medications, making them especially useful for localized pain.1
First-Line
Topical NSAIDs recommended as first-line for knee osteoarthritis2
Advantages
- Targeted delivery to painful area
- Fewer GI side effects than oral NSAIDs
- Less systemic absorption
- Good for localized pain
- Can be used with other treatments
- Many available over-the-counter
Topical NSAIDs
Anti-inflammatory medications in topical form:3
Products
- Diclofenac gel (Voltaren): Now OTC, well-studied
- Diclofenac solution (Pennsaid): Prescription
- Diclofenac patch (Flector): Prescription
Evidence
- Effective for osteoarthritis, especially knee and hand
- Comparable efficacy to oral NSAIDs for local pain
- Much lower systemic absorption
- Recommended by osteoarthritis guidelines
How to Use
- Apply to clean, dry, intact skin
- Rub in gently
- Don't cover with bandage unless directed
- Wash hands after application
- Avoid sun exposure on treated area
Cautions
- Can cause skin irritation
- Avoid on broken skin
- Use caution with oral blood thinners
- Still some systemic absorption—caution with kidney/heart issues
Lidocaine Products
Local anesthetic that numbs the area:4
Products
- Lidocaine patches (Lidoderm): Prescription 5%
- OTC patches: Lower strength (4%)
- Lidocaine creams and gels: Various strengths
Evidence and Uses
- FDA approved for postherpetic neuralgia
- Often used for other localized neuropathic pain
- May help some musculoskeletal pain
How to Use Patches
- Apply up to 3 patches at once
- 12 hours on, 12 hours off
- Can cut to fit area
- Apply to intact skin only
Capsaicin
Derived from hot peppers:5
How It Works
- Depletes substance P (pain signaling chemical)
- Desensitizes nerve endings over time
- Requires regular use for effectiveness
Products
- OTC creams: 0.025%-0.1%
- High-concentration patch (Qutenza): 8%, applied in office
Uses
- Neuropathic pain (diabetic neuropathy, postherpetic neuralgia)
- Osteoarthritis
- Chronic musculoskeletal pain
Important Notes
- Causes burning sensation initially—this improves with regular use
- Must use consistently (3-4 times daily) for weeks to work
- Avoid mucous membranes and eyes
- Wash hands thoroughly after applying
Counterirritants (Menthol, Camphor)
Create sensation of cooling or warmth:
Products
- Bengay, Icy Hot, Tiger Balm, Biofreeze
- Contain menthol, camphor, methyl salicylate
How They Work
- Create cooling or warming sensation
- May distract from pain
- Activate nerve receptors that may modulate pain signals
Considerations
- Relief is temporary
- Generally safe when used as directed
- Some contain methyl salicylate (aspirin-related)—avoid excessive use
- Don't use with heating pads
Compounded Topicals
Custom-made by compounding pharmacies:
Common Ingredients
- Combinations of multiple medications
- May include NSAIDs, lidocaine, muscle relaxants, others
- Customized formulations
Considerations
- Often expensive
- Limited research on many combinations
- Quality varies by pharmacy
- May be helpful when commercial products insufficient
Choosing a Topical Treatment
For Osteoarthritis
- Topical NSAIDs (diclofenac) first-line
- Capsaicin as alternative
For Neuropathic Pain
- Lidocaine patches
- Capsaicin (regular use required)
For Muscle Pain/Strains
- Counterirritants for temporary relief
- Topical NSAIDs
General Tips
- Apply to intact skin only
- Wash hands after application (unless hands are treatment area)
- Don't use with heating pads
- Give treatments adequate trial before judging (2-4 weeks)
- Store as directed
- Read and follow label instructions
Safety Note
Don't use multiple topical products on the same area unless directed. Some combinations can cause skin irritation or excessive medication absorption. Check with pharmacist if unsure about combining products.
Learn About Other Treatments
Explore comprehensive pain management approaches.
Heat and Cold Therapy GuideReferences
- Derry S, Wiffen PJ, Kalso EA, et al. Topical analgesics for acute and chronic pain in adults—an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;5(5):CD008609.
- Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;72(2):220-233.
- Derry S, Conaghan P, Da Silva JA, et al. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;4(4):CD007400.
- Derry S, Wiffen PJ, Moore RA, Quinlan J. Topical lidocaine for neuropathic pain in adults. Cochrane Database Syst Rev. 2014;(7):CD010958.
- Derry S, Rice AS, Cole P, et al. Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2017;1(1):CD007393.