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Topical Pain Creams and Lotions
A Background of the Source of my Expertise on this Topic
In my experience, topical medications can provide quantifiable improvement in pain and function in patients who either can't tolerate oral medications due to side effects or have not benefited from oral administration of the drug. However, there are several important factors to keep in mind when selecting an appropriate topical medication/cream. Over the last 13 years, I have researched dozens of topical medications/creams and have recommended their use for some patients who clearly met the appropriate criteria. Because I am involved in the care of worker's compensation patients with often severe chronic pain issues, I have had the unique opportunity to compile my own "mini" anecdotal evidence regarding outcomes and side effects, etc. With this knowledge, I hope to provide you with unique recommendations for the use of these medications and unique cautionary statements in some cases. Although your doctor likely has some knowledge about topical medications, I consider myself to be an expert and will likely provide a more detailed description.
At this time, it is necessary to note that this article is for informational purposes only and is intended to be a resource that you can use to start a conversation with your doctor about your treatment plan. You should never start a new medication or discontinue a medication that you are already taking unless you speak with your doctor. Any medical information contained herein should not be viewed as a substitute for a clinical visit at a hospital or a doctor’s office and should not be viewed as medical advise, as no history or physical exam have been performed. Additionally, any contradiction to the advice of your personal practitioner should not be viewed as being a justification to start or stop any recommended medical treatments.
Suffering from Chronic Pain?
Classes of Topical Medications
While it would not be possible for me to go over all of the different topical medications that are currently available for use, there are specific classes of medications that are more commonly used. Each class of medication has different indications for use, as well as different risks/benefits. Most of my knowledge on these drugs is through my job working as a Physician Assistant. However, when applicable, I will cite the use of the Official Disability Guidelines (ODG). The ODG guidelines can be found online. Unfortunately, the ODG guidelines can only be accessed with a paid account, which is very expensive. Although I could provide a link to the ODG guidelines, it is unlikely that the link would direct you to the appropriate page/reference without a paid account. These ODG guidelines are from the Work Loss Data Institute and are extremely detailed and all-encompassing of treatments, medications, diagnostics, surgeries, therapies, consults, etc. that a worker may need after an injury. They have been an invaluable resource to me in the course of the last 13 years of work in the California worker's compensation industry. Recent changes to California laws on 12/1/17 now require the use of ACOEM (American College of Orthopedic and Environmental Medicine) guidelines in determining an injured worker's course of treatment, but they also still recommend using ODG when the topic is not covered in ACOEM.
What different classes of topical medications are available?
I will be including information about the following:
- NSAIDs (nonsteroidal anti-inflammatory medications)
- Muscle relaxants
- Neuropathic agents (gabapentin, AEDs)
Classes of Topical Medications
Anti-inflammatories (NSAIDs) e.g. Ibuprofen or Naproxen
Used in acute and chronic pain, effective for mild pain, used for multiple conditions, fairly inexpensive, non-prescription, generic, not expensive, taken every 4-6 hours
Used for acute pain, not proven effective for chronic pain, not indicated for pain that lasts greater than 2 weeks, applied locally to painful area 2-3 x/day, inexpensive, easy to apply
Muscle relaxants (e.g. Baclofen, cyclobenzaprine)
Indicated for acute pain related to muscle spasm, short term use only, 2-3 weeks, prescription only, sedating, addictive with long term use, can interact with opioids and pain medications, controlled by FDA, doctors hesitant to prescribe
Topical formulation used locally for painful muscle spasm, prescription only
Anti-seizure medications/anti-epileptic drugs/AEDs) e.g. Gabapentin, Lyrica
Indicated in the treatment of chronic pain related to neuropathy, first line for neuropathic pain, can be sedating, relatively well tolerated, not regulated by FDA, generic, prescription only
Applied locally for nerve pain, prescription only, expensive, usually combined with other agents
Glucoasamine is taken orally, for arthritis, mild pain, effects work over a period of weeks, safe to use long term, minimal side effects, no interactions with other drugs, over the counter
Capsaicin and Glucosamine are available topically, only recommended when oral medications don't work or aren't tolerated, moderately priced, applied locally for arthritis and nerve pain
When used orally, it is only used in limited settings, not used for pain relief
Used topically for nerve pain, available as patch, cream, gel, applied locally to area, not really helpful for the spine or shoulder, relatively non-expensive
Risks/Dangers of Topical Medications
Topical medications have several risks associated with their use. While they are not usually absorbed into the body, they can be. If applied in large amounts over large areas, there is a significant concern for systemic exposure. Additionally, after application of creams, without proper hand washing, contamination of food, silverware, cups, or other items is possible and could ultimately result in a portion of the topical medication being ingested orally.
Several years ago, I recall hearing a devastating story about a young mother who had been given topical tramadol that was combined with lidocaine and ketoprofen to apply locally to her back. After applying it to her back, she then went and made her infant son his bottle. She subsequently sat and fed the infant his bottle all the while being completely unaware that she had lethal amounts of medication on the surface of her hands. The infant boy later died in his crib and the autopsy determined that he died of a drug overdose from lethal levels of tramadol and lidocaine. The mother was charged with child abuse, and blamed for the death of her son until it was later determined that the source of the drug had been a topical cream she had applied to her back.
This obviously is a very severe potential outcome, but it clearly illustrates that there are risks and side effects from topical medications. Proper handling of the medication, and proper hand washing after application could prevent serious contamination and systemic exposure.
Some of the topical medications are more likely to cause side effects than others. In my opinion, one of the more dangerous of the topical medications that I mentioned is lidocaine. Lidocaine is sometimes given in a dermal patch formulation that is just intended for application to the painful area. The benefits of the patch are many: ease of use, no messy cream/gel, nice packaging, relatively inexpensive.
However, lidocaine is also available in a cream/gel. In 2007, the FDA issued a warning about the use of topical lidocaine. The FDA reported that patients who applied too much or who used it over large areas of their body or a lot of times per day could actually have some systemic accumulation. Lidocaine is a serious medication when used systemically, sometimes used for cardiac patients during life saving procedures for heart arrhythmias. The FDA had not previously noted the possibility for systemic accumulation and, up until their advisory, the consensus was that it could be applied whenever, however, wherever, it didn't matter, it wouldn't end up in your blood stream. That is now proven to be wrong. Some patients had serious life threatening side effects and the FDA has now issued an update, which recommends the use of lidocaine as a patch only. Despite the advisory, it is all too common for pain management doctors to prescribe lidocaine as a cream and/or gel mixed with other agents. Often times, the doctor's that prescribe the lidocaine don't warn of the serious life threatening systemic effects. It is always important to ask your doctor to tell you the worst case scenario and get the full gamut of potential side effects with any medication, as has been shown in this example.
Some topical medications cause rash, dermatitis, discoloration of the skin, etc. Some topical creams can actually cause permanent discoloration of skin, so read the drug information carefully and/or ask your doctor.
Another serious concern is the risk of photocontact dermatitis with the use of topical Ketoprofen, which is a topical NSAID or anti-inflammatory medication. The FDA does not currently recommend topical use of Ketoprofen given the risk for photocontact dermatitis, which can cause scalding burns from sun exposure and a rash. However, as in the example with lidocaine, doctors continue to prescribe this topical medication for patients, often mixed with other medications. Always ask your doctor to tell you all the potential side effects before you use medications, and, as I have proven here, even topical medications.
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Where is your chronic pain?
© 2013 Kortney Tholen