Living With Chronic Pain

Topical Treatments for Chronic Pain

Pain management is never easy. It requires fine tuning and updating as symptoms change. Too often, we reflexively look to pills when a better, safer method is available – topicals. They can offer the same relief as orals, without the side effects or drug interactions.

Topical pain relievers are applied directly to the area of pain, allowing medication to penetrate through the skin at the exact site it’s needed. Because they absorb through the skin, joints closer to the surface, i.e. hands, feet, and knees, may get better relief.

Tópicas are helpful for:

Topicals can be over-the-counter or prescription remedies. Often the prescription product has a higher content than it’s OTC counter part. They may contain:

  • NSAIDs non steroidal anti inflammatory drugs. These contain medications such as Aleve and Motrin. Voltaren gel used to be prescription but is now available over-the-counter.
  • Aspirin type topicals contain salicylic acid. These include Bengay and Aspercream. Thankfully they now offer scent free versions. It took multiple washes to get the scent out of my bed linens after I’d slathered it on one night due to a particularly active day.
  • Capsaicin topicals such as Zostrix contain the active ingredient in chili peppers causing a burning sensation when applied. They work by depleting nerve cells of a chemical required to send pain messages. They may burn initially, but often lessens in time.
  • Anesthetics such as lidocaine help numb the painful area. It’s been used in gels (for dental pain), creams, sprays and my favorite- patches. They can be toxic in high doses, so use is restricted to twelve hours each day. I save them for nighttime when there’s nothing to distract me from my pain and sleep is a priority.
  • Menthol or camphor topicals produce a sensation of hot or cold that temporarily decreases pain sensation. They act as a counter irritant causing mild inflammation in the skin in order to lessen inflammation below its application in the joints, tendons or muscles. They differ from analgesics in that they don’t suppress pain but rather stimulate a response to ease it.
  • Ketamine has limited uses as an analgesic because of its addiction potential, but used topically it is devoid of serious consequences and often helpful in neuropathic and complex pain syndromes.
  • Compounded topicals use a variety of ingredients that may be beneficial directly on the source of the pain, especially when they aren’t tolerated orally. Medicines such as gabapentin, cyclobenzaprine, baclofen, and verapamil are often used in these preparations.
  • Narcotic products such as fentanyl are not included in this discussion.

Are they safe?

Do not use if allergic to any component in a topical preparation. In those with gastrointestinal issues such as indigestion, or if you have early renal issues such as CKD stage 3 – chronic kidney disease, oral agents are not recommended. But topicals are minimally absorbed into the blood stream, making these a viable alternative in some patients. Always clear with your provider first.

Even though absorption into the bloodstream is minimal, clear with your provider before using additional oral agents. Tylenol or acetaminophen, if not contraindicated is an acceptable alternative.

  • Never use NSAIDs or aspirin topicals if you are on anti- coagulants such as Coumadin or eliquis. There is a risk of bleeding.
  • Topicals can be used with ice packs, but use caution with hot ones. Heat increases their absorption into the blood stream.
  • Do not use on open wounds or skin already irritated.
  • Wash hands before and after each application and do not apply near eyes or genitals.
  • Try a small amount first. If there’s any issue, remove excess and cleanse area thoroughly.
  • Stop if a rash occurs
  • Never use when pregnant.
  • Follow instructions carefully, although rare, even these can cause serious side effects or reach toxic levels when applied inappropriately.
  • Seek medical help if they do not help after 1-2weeks.

What delivery system works best?

  • Patches work well on large flat surfaces, do not need to be reapplied throughout the day and have the benefit of not rubbing off on clothes, but some fall off when active and sweating. I especially prefer patches to creams on my back, they seem to penetrate deeper and offer relief longer.
  • Creams and gels are perfect for areas that move a lot such as knees and hands. Patches do not adhere well to these areas.
  • Topicals, especially creams and gels, work best with superficial joints.
  • Sprays are good for coating a wider surface area.

Do they work?

Some studies have shown topical treatments with NSAIDs work as well as their oral counterpart. Especially in cases where orals are poorly tolerated or contraindicated. In another study, the 5% prescription strength lidocaine patch effectively reduced the intensity of all common pain qualities in patients with moderate-to-severe chronic neuropathic and low back pain. A 2019 study refuted claims that compounded creams containing agents such as ketamine, baclofen, or cyclobenzaprine are any better than placebos. But this was a small study of only 400 participants that didn’t test a wider variety of products such as those with distinctive scents that prevent double blind reporting, or specify if a certain product helped a particular complaint (muscle but not neuropathic). Since it’s a billion dollar industry, far more investigation is required to see when and how they benefit pain sufferers.

I can tell you they make a huge difference in my life when I need a little extra help to get through a tough day or sleepless night. And from my patients overwhelmingly positive responses, I believe it’s a great alternative to pills, or a perfect adjuvant therapy to decrease oral intake. With relatively low side effects why not give one a try and see if it can ease your pain?



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