Is Qutenza (capsaicin) effective for treating severe foot neuropathy?

Qutenza (Capsaicin 8% Patch) for Severe Foot Neuropathy

Capsaicin 8% patch (Qutenza) is effective for treating severe foot neuropathy and is FDA-approved for diabetic peripheral neuropathy pain, offering significant pain relief with the advantage of avoiding systemic side effects. 1

Mechanism and Efficacy

Capsaicin works by:

• Binding to TRPV1 receptors on nociceptive nerve fibers
• Decreasing release of neurotransmitters like substance P
• Initially causing desensitization, followed by prolonged pain relief

The evidence supporting Qutenza for neuropathic pain is robust:

• One high-quality study supports the 8% patch specifically for diabetic peripheral neuropathy 1
• Pain relief typically begins within 1-7 days of application 2
• Effects last an average of 5 months after a single application 2
• Some patients experience pain relief lasting up to 18 months 3

Application Protocol

For severe foot neuropathy:

• Apply up to 4 patches to cover painful areas
• Single 30-minute application
• Can be repeated every 3 months as needed 1
• Pre-treatment with 4% lidocaine for 60 minutes is recommended to reduce application discomfort

Advantages Over Oral Medications

Qutenza offers several benefits compared to oral neuropathic pain medications:

• Avoids systemic side effects common with gabapentinoids, SNRIs, and TCAs
• No drug interactions
• No daily dosing required
• May be particularly beneficial for patients with:
  • Contraindications to oral medications
  • Preference for topical treatments
  • Elderly patients at higher risk for medication side effects
  • Patients with polypharmacy concerns

Recent Evidence for Disease Modification

Beyond pain relief, emerging evidence suggests Qutenza may have disease-modifying effects:

• Recent studies show it can promote regeneration and restoration of skin nerve fibers in diabetic neuropathy 4
• Increased intra-epidermal nerve fiber density has been observed 3 months after treatment 4
• This regenerative effect correlates with pain relief and may potentially prevent diabetic foot complications 4

Common Side Effects

Most side effects are localized and transient:

• Erythema
• Burning sensation
• Application site pain
• These typically resolve shortly after application 5

Place in Treatment Algorithm

For severe foot neuropathy:

1. First-line options:

   • Gabapentinoids (pregabalin, gabapentin)
   • SNRIs (duloxetine, venlafaxine)
   • TCAs (amitriptyline)

2. Consider Qutenza when:

   • First-line medications are ineffective
   • Patient cannot tolerate oral medication side effects
   • Patient prefers topical treatment
   • Patient has contraindications to oral therapies

3. Combination therapy:

   • Qutenza can be used in combination with oral medications for enhanced effect
   • May allow reduction in oral medication doses

Special Considerations

• Patients should be counseled that initial application may cause temporary burning or stinging
• The patch should be applied by healthcare professionals trained in its use
• Qutenza is not appropriate for open wounds or broken skin
• Regular reassessment of pain relief and function is recommended

Qutenza represents an important option for severe foot neuropathy, particularly for patients who cannot tolerate or do not respond adequately to oral medications, with the added potential benefit of promoting nerve regeneration.