Prescription Topical Arthritis Pain Relief
Physicians typically prescribe topical medications to patients who
- Do not get satisfactory pain relief from over-the-counter medications
- Have sensitivities to oral medications
- Have stomach ulcers or other conditions that can cause gastrointestinal bleeding
See Dysphagia and Difficulty Swallowing Medications
In the U.S., prescription topical arthritis pain medications currently include:
- Topical NSAIDs
- Certain lidocaine products, such as 5% lidocaine patches
Like all prescription medication, topical pain relief products are potentially toxic. Patches should be kept away from pets and children and folded and disposed of properly after use.
See What Pain Management Approach Works Best?
Prescription Topical NSAIDs
Research evidence suggests topical non-steroidal anti-inflammatory drugs (NSAIDs) reduce arthritis pain as well as oral NSAIDs.1,2 In the U.S., topical NSAIDs for arthritis pain are made with an active ingredient called diclofenac.
Two commonly prescribed diclofenac products are:
- Voltaren Gel, which is FDA-approved to treat pain caused by osteoarthritis in the knees, ankles, feet, elbows, wrists, and hands.
- Pennsaid topical solution, which is FDA-approved to treat pain caused by knee osteoarthritis
See What Is Osteoarthritis?
See What Is Knee Osteoarthritis?
Neither product is formally approved for use on deeper joints, such as the shoulder, hip, and low back.
Topical diclofenac users should follow manufacturers’ instructions and carefully measure doses according to the joint being treated. Upper extremity joints (e.g. elbows) require smaller amounts than lower extremity joints (e.g. knees).
Other types of topical NSAIDs, with active ingredients such as ibuprofen or ketoprofen, may be available in Europe or special-ordered from compounding pharmacies. These products may become more widely available in the U.S. in upcoming years.
In This Article:
- Topical Pain Relief for Arthritis
- Over-the-Counter Topical Arthritis Pain Relief
- Prescription Topical Arthritis Pain Relief
- Uncommon Prescription Topical Analgesics for Arthritis Pain
Topical NSAIDs: Potential side effects and drug interactions
The most common side effect of topical NSAIDs is dry skin at the application site.3,4
Topical diclofenac medication has absorption locally, at the site of the painful joint, as well as into the bloodstream. This means topical diclofenac products:
- May pose gastrointestinal side effects, though these side effects tend to be less frequent than with oral NSAIDs.5
- Interact with oral medications, such as oral NSAIDs, aspirin, anticoagulants (e.g. warfarin), and methotrexate.
- Are not ideal for people who have three or more painful joints. Applying medication to several joints can result in too much medication being absorbed through the skin. (For these people, oral medications may be more appropriate.)
In addition, topical NSAIDs may pose other potential risks. For example, the FDA warns that Voltaren Gel poses a potential risk to the liver, and advises patients to tell their doctors if they have liver problems before using diclofenac products.6
To decrease the risk of side effects and interactions, patients should tell their health care provider about medications and supplements they are currently taking.
Prescription Topical Lidocaine
Lidocaine is a local anesthetic sometimes used to treat arthritis and other musculoskeletal pain. It is sold in over-the-counter products as well as in prescription products, including ointments, gels and creams as well as adhesive patches that contain lidocaine solution.
Evidence suggests that 5% lidocaine patches help relieve arthritis pain.7 These patches, sold under the brand name Lidoderm Patch, offer some patients deep pain relief. (One limitation of all topical lidocaine products is that lidocaine does not always penetrate deep below the skin, where joint pain originates.)
Potential side effects and drug interactions
Topical lidocaine numbs the skin and should not be used while icing or heating the painful joint.
See 3 Types of Cold Packs for Arthritis
It is possible for topical lidocaine to enter the bloodstream. If too much lidocaine is absorbed through the skin, a person can experience serious side effects, such as irregular heartbeats, breathing problems, seizures, and coma. People are advised to use this medication as directed and avoid using more than necessary. For example, Lidoderm Patch users are instructed to use three or fewer patches and to spend at least 12 hours per day without any patches.8
- 1.Zhang Y, Shi S, Chen X, Peng M. Functionalized magnetic nanoparticles coupled with mass spectrometry for screening and identification of cyclooxygenase-1 inhibitors from natural products. J Chromatogr B Analyt Technol Biomed Life Sci. 2014 Jun 1;960:126-32. doi: 10.1016/j.jchromb.2014.04.032. Epub 2014 Apr 26. PubMed PMID: 24793085.
- 2.Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012 Sep 12;9:CD007400. doi: 10.1002/14651858.CD007400.pub2. Review. PubMed PMID: 22972108; PubMed Central PMCID: PMC4160008.
- 3.Roth SH, Fuller P. Pooled safety analysis of diclofenac sodium topical solution 1.5% (w/w) in the treatment of osteoarthritis in patients aged 75 years or older. Clin Interv Aging. 2012;7:127-37. doi: 10.2147/CIA.S30884. Epub 2012 Jun 11. PubMed PMID: 22791985; PubMed Central PMCID: PMC3393357.
- 4.Simon LS, Grierson LM, Naseer Z, Bookman AA, Zev Shainhouse J. Efficacy and safety of topical diclofenac containing dimethyl sulfoxide (DMSO) compared with those of topical placebo, DMSO vehicle and oral diclofenac for knee osteoarthritis. Pain. 2009 Jun;143(3):238-45. doi: 10.1016/j.pain.2009.03.008. Epub 2009 Apr 19. PubMed PMID: 19380203.
- 5.Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2012 Sep 12;9:CD007400. doi: 10.1002/14651858.CD007400.pub2. Review. PubMed PMID: 22972108; PubMed Central PMCID: PMC4160008.
- 6.FDA MedWatch Safety Alerts: December 2009. Food and Drug Administration. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm196683.htm Updated February 2010. Accessed November 14, 2015.
- 7.Gammaitoni AR, Galer BS, Onawola R, Jensen MP, Argoff CE. Lidocaine patch 5% and its positive impact on pain qualities in osteoarthritis: results of a pilot 2-week, open-label study using the Neuropathic Pain Scale. Curr Med Res Opin 2004;20 Suppl 2:S13-9. PubMed PMID: 15563742.
- 8.Lidoderm Lidocaine Patch: How Lidoderm Works. Endo Pharmaceuticals. http://www.lidoderm.com/dtc/how-lidoderm-works.aspx January 2013. Accessed November 14, 2015.
A Guide to Topical Pain Medications
“Certain patients have difficulty swallowing pills,” Dr. Patel says. “Other patients may have had surgeries that impede their ability to absorb drugs through their GI system. That’s when topical medications can be used to control pain.”
A pain relief cream or patch can also be used when you have pain in a very specific area. “If you have pain in a joint, you can put the medication on the joint, whereas if you take the drug orally, it goes through your whole body,” Patel says.
Related: Know Your Pain Treatment Options
Choices in Topical Therapy for Pain Relief
Consider these three main types of pain medication applied to the skin:
- Local anesthetics. These are medications that numb painful areas for short periods of time. They have a variety of uses. Lidocaine patches, for example, can help to relieve the burning, stabbing, chronic ache that may occur after a shingles infection — a condition called post-herpetic neuralgia. Dentists may also use a topical anesthetic on the gums to help ease the pain of an injection. Some topical local anesthetics are also available over the counter in spray and gel form to treat the sting of a sunburn.
- Pain medications. Medications applied to the skin include drugs such as the non-steroidal anti-inflammatory drug diclofenac (Solaraze, Pennsaid), which works by reducing inflammation in a localized area of the body, or aspirin creams, which work by blocking substances in the body that cause pain. Alternatively, these topical medications may contain narcotic pain relievers, such as fentanyl. Though some of these topical pain relievers (Aspercreme, BenGay) are available over the counter, some are dispensed by prescription only.
- Counter-irritants. These are products that contain substances such as menthol, eucalyptus, or oil of wintergreen that irritate nerve endings, producing a “cool” feeling on the skin and distracting the brain from deeper sources of pain. Vicks VapoRub is an example of a counter-irritant.
Related: Therapies for Natural Pain Relief
Topical Therapy for Pain Relief Cautions
Not everyone is a good candidate for topical therapy for pain relief. People who are allergic to the adhesives on patches, for example, should avoid them. Anyone who is sensitive to the active ingredient in an oral pain reliever should not try it in topical form either.
“People who have had kidney problems or kidney failure in the past, for example, shouldn’t try an ibuprofen cream,” Patel says. Don’t use a topical pain reliever on infected skin. “You won’t get as effective a result if there’s an active infection on the skin,” Patel explains. “It causes an imbalance in the environment, and it could negate the medication.”
Patel adds that people who use topical pain relievers shouldn’t apply too much. Overdose is possible, just as with oral medications.
Says Patel, “There will be specific directions on the patch or cream — a specific amount of cream you can apply or a certain number of patches you can use.” Always follow these directions.
When it comes to relieving the pain of achy joints, many people reach for a pain-relieving pill like aspirin or ibuprofen. There may be a better way. When the source of pain is close to the surface, applying a cream, gel, patch, or spray that contains a pain reliever right where it hurts can ease pain and help avoid some of the body-wide side effects of oral pain relievers.
As I write in this month’s Harvard Men’s Health Watch, these so-called topical analgesics work best for more superficial joints like the knees, ankles, feet, elbows, and hands. “In those areas, the medication can penetrate closer to the joint,” says Dr. Rosalyn Nguyen, a clinical instructor in physical medicine and rehabilitation at Harvard Medical School.
The active ingredient in most topical analgesics is a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen, naproxen, aspirin, or diclofenac. These medications target inflammation, which contributes to pain, swelling, and stiffness.
We know that oral NSAIDs can quell arthritis pain. Do they work as well when applied to the skin? A scientific review by the Cochrane Collaboration, an international body of health experts, found that some prescription topical NSAIDs can offer the same pain relief as oral medications with fewer gastrointestinal concerns.
The advantage of using a topical analgesic is that the medication works locally. Targeting pain more precisely using a medication applied to the skin can help skirt the side effects of oral drugs. This can be a boon for people whose stomachs are sensitive to NSAIDs. (Keep in mind that a small amount of the medicine still enters the bloodstream and ends up in the stomach and elsewhere, so a topical analgesic isn’t a guarantee against NSAID-related stomach irritation.)
Other people seek topical NSAIDs because they want to avoid adding another pill to their daily regimen, or have trouble taking pills.
Using a topical analgesic
Topical analgesics can be applied two to four times a day to control mild to moderate pain. Make sure to wash your hands thoroughly after use so you don’t smear the drug into your eyes, nose, mouth, or other mucous membranes.
Side effects from topical medications include redness, itching, and other skin irritation. They are generally mild—and uncommon. The cause of skin irritation is often the material used to make the cream or gel, not the NSAID, says Dr. Joanne Borg-Stein, medical director of the Harvard-affiliated Spaulding-Wellesley Rehabilitation Center in Massachusetts. When that happens, it’s possible for a pharmacist to create a preparation with ingredients that are less irritating to your skin.
A topical analgesic may not be the best choice when pain affects an extended area, like the lower back, or affects more than one part of the body.
A key warning about using topical analgesics: don’t use them if you are also taking an oral NSAID—either prescription or over-the-counter—without telling your doctor. Taking too much of an NSAID can land you in the hospital with stomach bleeding or an ulcer flare-up. In fact, up to 100,000 Americans are hospitalized every year for NSAID-related gastrointestinal problems.
Availability and cost may limit the use of topical NSAIDs. In the United States, the only prescription topical NSAID widely available in pharmacies is diclofenac gel. Other types, such as ibuprofen, ketoprofen (Orudis), indomethacin (Indocin), and piroxicam (Feldene) may require a special order from a compounding pharmacy.