- Health Care, Drugs & Insurance
Topical Pain Creams/Gels and Their Benefits
When Pain Is a Problem, Topical Creams Can Provide a Solution
Topical medications: Do they work?
There are several different classes of prescription topical medications that are available today. While these types of medications are not generally recommended as part of an initial treatment, they can be a valuable treatment option in some cases. Typical first line medications would include oral NSAIDs, such as ibuprofen or Naproxen, muscle relaxants, such as Baclofen or Flexeril, and opioid medications, such as Oxycodone, Hydrocodone, and Morphine. However, with the exception of NSAIDs, the other 2 most commonly used medications for pain (opioids and muscle relaxants) have significant risks for dependence, addiction, abuse, and overdose, especially with long term use of more than 1-2 months. As a result, they are not generally indicated for long term use or for patients with only mild pain. As discussed in another one of my hubs on this topic, concerns for opioid use have been growing over the last two decades and at this point, the opioid problem in the United States and other countries has become somewhat of an epidemic. In an attempt to prevent opioid dependence and addiction, treatment alternatives are necessary. Topical medications could be a good treatment alternative in some cases. However, there are also potential risks with topical medications, as well, and their efficacy in treating more severe forms of pain is questionable. When considering topical medications, physicians need to be fully informed on the specific indications for each class of topical medication, as well as their potential adverse effects.
It is important to note that my intention with this hub/article is to provide information on these medications. This article does not imply a recommendation for treatment for any particular patient. You should never stop taking a medication that is prescribed by a doctor without their consent and before starting any of these medications, it is also necessary to consult with your doctor. I am unable to provide recommendations for treatment or prescriptions for patients that I do not physically see in the office for a physical examination and complete history taking. This information can be used to initiate a conversation with your doctor about this type of treatment.
As outlined in the Official Disability Guidelines from the Work Loss Data Institute, "topical pain medications are applied locally to painful areas with advantages that include lack of systemic side effects, absence of drug interactions, and no need to titrate." Several different classes of medications can be used topically, including anti-inflammatory medications (NSAIDs), opioids, local anesthetics, cannabinoids, anti-depressants, and muscle relaxants. Topical application of medications does not include transdermal medications, such as the opioid fentanyl, as transdermal is intended to penetrate the skin layers into the tissues with systemic effects and topical medications are indicated for focal effects without any systemic exposure. Topical medications in general are considered to be experimental/investigational, as there are very few evidence based studies that have proven efficacy. It is common for many of these agents to be compounded into one topical cream, but in general if only one of the medications in the topical cream is not indicated for use for the condition, then the entire cream would not be appropriate to use. One of the more common conditions that is treated with topical medications would be neuropathic (nerve) pain. However, topical medications are generally not recommended until after oral medications have already been tried and either have failed to provide benefit or caused intolerable adverse effects. One of the primary benefits with topical application of medication is that it is not absorbed into the blood stream, metabolized by the liver, or excreted by the kidneys, as would be the case with oral medications, so there is less risk for systemic problems, such as liver/kidney damage, gastrointestinal problems, and addiction.
Topical Anesthetics (Lidocaine)
Local anesthetics, like lidocaine, bupivicaine, and benzocaine, are used commonly for dental procedures. Lidocaine is also used as a numbing agent for many injections. This medication can be applied topically and is most recommended when there is nerve pain. However, oral medications should be tried first. Lidoderm is a topical patch applied to the skin that delivers lidocaine locally. The FDA notified the public in 2007 of a potential hazard of the use of topical lidocaine, especially when it is applied to large areas and left on for a long time, this can lead to systemic exposure and effects. As such, it is generally not appropriate to use lidocaine in any other formulation than a transdermal patch wherein a controlled amount of the medication is being applied.
Topical lidocaine patches
Topical lidocaine is currently only FDA approved in a patch formulation. My husband uses Aspercreme patches on his lower back, which seem to help especially when he has a flare up or at night to help with sleep. I’ve also used these patches on my knee when I’m having pain and they work great!
Topical lidocaine cream
Capsaicin is a topical analgesic medication that can be applied locally and is only recommended if oral medications cannot be tolerated. It is mostly recommended for nerve pain, but there are also studies that have found a positive effect on arthritis, fibromyalgia and back pain with this agent. It is mostly considered to be experimental, however, at large doses. Capsaicin comes from chili peppers and is literally the agent in the chili peppers that makes your mouth feel hot. It can provide a local heating type of sensation, which is intended to open up blood vessels to allow blood and other healing properties in the blood to heal the local injury.
Topical Capsaicin Cream
Topical Muscle Relaxants
Muscle relaxants have been used as topical medications and are being researched to evaluate for possible positive effects. Baclofen, a muscle relaxant medication that is commonly prescribed orally to address painful muscle conditions, is currently in a Phase III study at the Institute of Health, in which it is being studied for its possible benefit for chemotherapy related nerve pain. However, it is still experimental at this time and there is actually no research that has proven a positive effect with topical muscle relaxants. No other muscle relaxant medications are proven effective or beneficial for topical use.
Topical NSAIDs (Non-Steroidal Anti-Inflammatory Agents)
Topical NSAIDs, such as diclofenac and ketoprofen, are generally indicated in the treatment of osteoarthritis in joints that are amenable to topical treatments, such as in the knee, elbow, wrist, hand, ankle, and foot. However, they are only recommended for short term use of up to 4-12 weeks, as chronic use beyond 12 weeks has not been found to be efficacious. NSAIDs were recently found to be helpful for acute soft tissue injuries, such as sprains and overuse injuries, as determined in an evidence based studied, but they are only recommended for very short term use of 1-2 weeks. However, the oral formulation would be recommended first unless there were contraindications to the oral formulation (such as history of gastric ulcers, liver/kidney damage/failure, cardiovascular disease, etc.).
The intention with topical NSAIDs is to achieve a therapeutic concentration of the medication in the tissues around the location where it was applied. This prevents the systemic exposure to the medication, which can decrease the risks for GI and cardiovascular events. However, at this time, the only FDA approved topical NSAID is diclofenac. Multiple other NSAIDs have not been proven to be similarly efficacious for topical use. Some side effects have been reported with the use of NSAIDs topically, including a rash or itching at the application site. However, these side effects have only been reported in 12% of patients who use topical NSAIDs and the rash/itching resolves once the medication is discontinued. It is also important to note that topical NSAIDs are considerably more expensive (6 to 10 times) that oral formulations. However, it has been theorized that the fact that patients are less likely to have the GI and cardiovascular side effects provides a cost savings long term.
Other Topical Agents
The multiple other different classes of topical medications have limited proven benefit. Agents like gabapentin (AEDs) and antidepressants have not been proven to be efficacious and there are no peer reviewed studies that show any efficacy with their use. Salicylates and menthol have some evidence of benefit from pain, but are only recommended when oral medications are not helpful. Additionally, the FDA has released a warning that topical medications that contain menthol and salicylates may cause severe burns.
It is ultimately up to the individual to decide what medications work well. In some cases, a medication may work, while in other cases with similar diagnoses, the same medications may not help.
In general, it appears that topical medications do not offer a very promising alternative to oral medications to treat pain related to arthritis, muscle spasm, nerve problems and injury. Most physicians who specialize in orthopedics, physical medicine and rehabilitation (PM&R), and pain management, however, commonly use topical medications to supplement the oral medications prescribed in hopes that the topical medication will help the patient to decrease the need to rely on oral medications to address pain. Nonetheless, treatment response is variable, and not proven, thus, topical agents do not provide a reliable alternative to oral medications.
What topical medications have you tried in the past?
Ultra Strength BenGay combines menthol with methyl salicylate and capsaicin. This medication is available over the counter and can be used immediately following an injury to provide local relief. I have also recommended it for use after exercise in painful muscles, as it provides a heating effect to those muscles and allows some pain relief.
© 2012 Kortney Tholen