Recommended Concentrations for Compounded Pain Cream
For a compounded pain cream containing diclofenac, baclofen, lidocaine, ketamine, and gabapentin, the recommended concentrations are: diclofenac 3%, baclofen 2%, lidocaine 5%, ketamine 10%, and gabapentin 6%. 1, 2, 3, 4
Evidence-Based Concentrations for Each Component
Lidocaine
- 5% concentration is the most commonly recommended formulation for neuropathic pain, providing local anesthesia with minimal systemic absorption 5
- Available in both patch and cream/gel formulations, with patches being more effective than gel due to gradual delivery over hours 1
- Should only be applied to intact skin over the area of maximal pain 5
Diclofenac
- 3% concentration is effective for topical pain management 2
- 1% gel is also commonly used and is often the most requested agent by patients 2
- Should be taken with food to minimize gastrointestinal side effects when used orally 6
Ketamine
- 10% concentration is effective for topical pain management in compounded formulations 2, 3
- Works as an N-methyl-D-aspartate (NMDA) receptor antagonist in peripheral terminals of primary nociceptive afferents 1
- Can be compounded with other agents to extend duration of effect to 2-3 times daily application 2
Gabapentin
- 6% concentration is effective for topical pain management 2, 4
- Penetration and retention in the skin is dependent on the base used, with poloxamer lecithin organogel showing the best results 4
- Topical 5% gabapentin has shown similar reduction in nociception as systemic gabapentin in preclinical models 4
Baclofen
- 2% concentration is typically used in compounded pain formulations 7
- Often included in formulations for nociceptive and mixed pain 7
Application and Usage Guidelines
- Apply to intact skin over the area of maximal pain, avoiding broken or inflamed skin 5
- Apply 2-3 times daily for optimal pain relief 2
- An adequate trial requires at least 3 weeks to properly assess efficacy 5
- Most common adverse effects are mild application site reactions such as erythema or rash 5
Efficacy Considerations
- Compounded pain creams may not show superior efficacy compared to placebo in some studies, suggesting careful consideration of cost versus benefit 7
- The choice of vehicle/base significantly affects drug penetration and efficacy 4
- Lipoderm or similar specialized bases may be preferred for optimal drug delivery 4
- Pain relief typically begins within 30 minutes of application but duration varies based on formulation 2
Cautions and Monitoring
- Monitor for local skin reactions, which are the most common adverse effects 5
- Avoid using on broken or inflamed skin 5
- Avoid applying external heat sources over the application area 5
- Systemic absorption is minimal with proper application, making these formulations safer than oral alternatives 3
Special Considerations
- For elderly patients or those with sensitive skin, consider starting with lower concentrations and titrating as needed 6
- The efficacy of compounded formulations may depend on the specific pain condition being treated 1, 7
- Combination therapy with these agents may provide better pain relief than monotherapy for complex pain conditions 1