What are the treatment options for neuropathic pain on the hands?

Treatment of Neuropathic Pain on the Hands

For neuropathic pain affecting the hands, start with topical lidocaine 5% patches or capsaicin 0.075% cream applied 3-4 times daily as first-line therapy, given the localized nature and minimal systemic side effects. 1, 2

Topical Treatments (First-Line for Localized Hand Pain)

Topical agents are the preferred initial approach for hand neuropathy because they provide minimal systemic side effects, no drug interactions, and no need for dose titration. 1

Lidocaine 5% Patches

• Apply daily to the painful areas of the hands 3, 4
• Provides localized pain relief with minimal systemic absorption 3
• Particularly effective for localized peripheral neuropathic pain with allodynia 3

Capsaicin Cream 0.075%

• Apply sparingly 3-4 times per day to affected areas of the hands 1, 2
• Important caveat: Pain may worsen during the first few weeks of application as substance P is depleted from nerve terminals 1
• Unless treating the hands themselves, wash hands thoroughly with soap and water immediately after application 2
• Works by releasing and depleting substance P from nerve terminals 1

High-Concentration Capsaicin 8% Patch

• Single 30-60 minute application can provide pain relief lasting up to 90 days 1
• Requires assisted application in clinical setting 1
• Particularly useful for refractory cases 1, 5
• May promote nerve fiber regeneration and disease modification, not just symptom relief 5

Topical Menthol 1% Cream

• Apply twice daily to affected hand areas and corresponding dermatomal region of spine 1
• Improvement in pain scores typically seen after 4-6 weeks 1

Compounded Topical Combinations

• Baclofen 10 mg + amitriptyline 40 mg + ketamine 20 mg gel shows effect after 4 weeks, especially on motor symptoms 1
• However, a large trial (n=462) of topical ketamine 2% + amitriptyline 4% showed no benefit 1

Oral Systemic Therapy (If Topical Treatments Inadequate)

First-Line Oral Agents

If topical treatments provide insufficient relief after 2-4 weeks, initiate oral systemic therapy with pregabalin or gabapentin as first choice. 1, 3

Pregabalin (α2-δ Agonist)

• Start 75 mg twice daily, titrate to 150-300 mg twice daily 3
• Preferred over amitriptyline due to superior adverse event profile despite similar efficacy 1
• Contraindications: Avoid in patients with edema 1
• Common side effects: Weight gain, peripheral edema, dizziness, somnolence 1, 6

Gabapentin (α2-δ Agonist)

• Start 100-300 mg at bedtime, gradually increase to 900-3600 mg/day in 2-3 divided doses 3
• Contraindications: Avoid in patients with edema or unsteadiness/falls 1
• Requires dose adjustment in renal impairment 3

Duloxetine (SNRI)

• Start 30 mg once daily for first week, then increase to 60 mg once daily 3
• Can increase to maximum 120 mg/day if needed 3
• Number needed to treat (NNT) of 5.2 for diabetic neuropathy 3
• Contraindications: Hepatic disease 1
• Fewer anticholinergic effects than tricyclic antidepressants 3
• Common side effects: Nausea (take with food to minimize), dizziness, somnolence, constipation 7

Tricyclic Antidepressants (TCAs)

• Nortriptyline or desipramine preferred over amitriptyline (fewer anticholinergic effects) 3, 7
• Start 10 mg/day in older adults, titrate slowly to maximum 75 mg/day 3
• Obtain screening ECG in patients over 40 years before starting 3
• Contraindications: Glaucoma, orthostatic hypotension, cardiovascular disease, unsteadiness/falls 1
• Limit to <100 mg/day when possible in cardiac patients 3
• Side effects: Dry mouth, orthostatic hypotension, constipation, urinary retention, cardiac toxicity 3, 7

Combination Therapy

If single-agent therapy provides partial but inadequate relief, add a second first-line agent from a different class rather than switching. 1, 3

• Gabapentin + nortriptyline combination more efficacious than either alone 1
• Low-dose gabapentin + morphine more effective than higher-dose monotherapy 1
• Critical: Trial each agent for at least 2 weeks at adequate dose before assessing efficacy 1, 3

Second-Line Oral Agents (If First-Line Fails)

Tramadol

• Start 50 mg once or twice daily, maximum 400 mg/day 3
• Dual mechanism: Weak μ-opioid agonist + inhibits serotonin/norepinephrine reuptake 1, 3
• Lower abuse potential than strong opioids 3
• Use lower doses in older adults and those with renal/hepatic dysfunction 3

Strong Opioids

• Reserve as salvage option only when other therapies have failed 1, 3
• Use smallest effective dose 1
• Risks include tolerance, dependence, cognitive impairment, respiratory depression 1, 3

Treatment Algorithm for Hand Neuropathy

1. Start with topical therapy: Lidocaine 5% patches OR capsaicin 0.075% cream 3-4 times daily 1, 3, 2

2. If inadequate response after 2-4 weeks: Add oral pregabalin (150-300 mg twice daily) OR gabapentin (900-3600 mg/day) 1, 3

3. If partial response: Add duloxetine (60 mg daily) OR TCA (nortriptyline 10-75 mg/day) from different class 1, 3

4. If still inadequate: Consider high-dose capsaicin 8% patch (single application, lasts 90 days) 1, 5

5. If refractory: Add tramadol (200-400 mg/day) or consider strong opioids as last resort 1, 3

Special Considerations for Hand Treatment

Patient-Specific Factors

Tailor treatment based on comorbidities and contraindications: 1

• Cardiovascular disease: Avoid TCAs, use duloxetine or gabapentinoids 1, 3
• Hepatic disease: Avoid duloxetine 1
• Renal impairment: Reduce gabapentinoid doses 3, 7
• Edema: Avoid pregabalin and gabapentin 1
• Falls risk/unsteadiness: Avoid TCAs and gabapentinoids 1
• Glaucoma: Avoid TCAs 1
• Older adults: Start all medications at lower doses, titrate slowly, prioritize topical agents 3, 7

Adjunctive Non-Pharmacological Approaches

• Physical exercise and functional training reduce neuropathic symptoms 1
• Coordination and sensorimotor training for hand function 1
• Consider transcutaneous electrical stimulation if medications fail 1

Common Pitfalls to Avoid

• Do not discontinue treatment prematurely: Allow minimum 2 weeks at therapeutic dose before declaring failure 1, 3
• Warn patients about initial capsaicin worsening: Pain may increase for first few weeks before improvement 1
• Remember to wash hands after capsaicin application unless treating the hands themselves 2
• Do not use opioids as first-line therapy: Reserve for refractory cases only 1, 3
• Screen ECG before TCAs in patients >40 years: Cardiac toxicity is a real concern 3
• Adjust gabapentinoid doses in renal impairment: Failure to do so increases side effects 3, 7