What are the options for a pain patch for local application?

Pain Patches for Local Application

Lidocaine 5% patches are the first-line, evidence-based choice for localized pain, offering effective relief with minimal systemic absorption and excellent tolerability. 1

Primary Recommendation: Lidocaine Patches

Lidocaine 5% patches should be applied daily to the painful site for up to 12-24 hours, with up to 3 patches used simultaneously for larger areas like feet. 1

Key Application Guidelines:

• Apply to clean, dry, intact skin only - never on open wounds, broken skin, or inflamed areas 2, 3
• Wear for 12-24 hours per day, then remove 1
• Wait at least 4 weeks to assess efficacy before switching treatments 1
• Avoid showering/bathing for at least 30 minutes after application 2
• Do not apply heat, occlusive dressings, or bandages over the patch 2, 3
• Wash hands thoroughly after application 2, 3

Evidence Supporting Lidocaine Patches:

• Patches deliver lidocaine gradually over hours, making them more effective than creams or gels 1
• Minimal systemic absorption occurs, reducing risk of toxicity 1
• Available over-the-counter in 4% concentration or prescription 5% strength 1
• Effective for neuropathic pain, postherpetic neuralgia, cancer-related pain, and myofascial pain 1
• Low to moderate-quality evidence supports efficacy and safety for acute localized pain 4

Alternative Patch Option: Diclofenac

Diclofenac patches (180 mg) can be applied once or twice daily for musculoskeletal and bone pain. 1

Diclofenac Application Guidelines:

• Apply to clean, dry skin over the painful area 2
• Use one patch daily or twice daily 1
• Avoid showering for at least 30 minutes after application 2
• Wait until area is completely dry before covering with clothing 2
• Avoid combining with oral NSAIDs unless benefit outweighs risk 2
• Protect treated area from natural and artificial sunlight 2

Evidence for Diclofenac Patches:

• Provides relief for bone metastases pain with minimal systemic effects 1
• Effective for osteoarthritis pain, particularly knee pain 2
• Acts locally as a coanalgesic with opioids, antidepressants, or anticonvulsants 1

High-Concentration Capsaicin Patches (8%)

Capsaicin 8% patches require controlled medical application, often with local anesthetic pretreatment, and provide pain relief lasting approximately 12 weeks. 1

Critical Application Requirements:

• Must be applied under highly controlled conditions by healthcare professionals 5
• Pretreatment with local anesthetic (EMLA cream) for 2 hours reduces application pain without interfering with desensitization 6
• Single application provides relief for approximately 12 weeks 5
• Causes intense initial burning sensation requiring careful monitoring 5

Evidence and Limitations:

• About 10% more participants report improvement versus placebo in postherpetic neuralgia and HIV-neuropathy 5
• NNT (number needed to treat) ranges from 7-12 for various neuropathic pain conditions 5
• Local adverse events (pain, erythema) are common; 3% experience transient hypertension from application pain 7, 5
• Moderate quality evidence supports efficacy, but effects are modest 5
• Repeated applications may cause painful nerve damage long-term 7

When to Consider Capsaicin:

• Reserve for refractory neuropathic pain unresponsive to lidocaine patches 7
• Particularly for postherpetic neuralgia, HIV-neuropathy, and diabetic neuropathy 5
• Only when benefit clearly outweighs the significant application discomfort 7, 5

Compounded Topical Formulations

For complex or refractory pain, compounded creams containing multiple agents may be considered, though evidence is limited. 1, 8

Evidence-Based Compounded Options:

Amitriptyline-Ketamine Combination:

• Amitriptyline 1-2% with ketamine 0.5-5% applied up to 3 times daily 1
• 75% of patients with erythromelalgia reported pain improvement 1
• Requires compounding pharmacy preparation 1
• Limited evidence in cancer-related pain; one trial showed no effect versus placebo 1

Multi-Agent Compounded Cream:

• Recommended concentrations: diclofenac 3%, baclofen 2%, lidocaine 5%, ketamine 10%, gabapentin 6% 8
• Apply to intact skin over maximal pain area 8
• Requires at least 3 weeks for adequate efficacy trial 8
• Monitor for mild application site reactions (erythema, rash) 8
• Consider lower concentrations for elderly or sensitive skin patients 8

Common Pitfalls to Avoid

• Do not apply any patches to broken, irritated, or inflamed skin 2, 3
• Do not use heating pads or occlusive dressings over patches 2, 3
• Do not combine topical NSAIDs with oral NSAIDs without careful monitoring 2
• Do not expect immediate results - allow 4 weeks minimum for lidocaine efficacy assessment 1
• Do not apply capsaicin patches without proper medical supervision and local anesthetic pretreatment 6, 5
• Avoid skin-to-skin contact with others until treated area is completely dry 2
• Do not use lidocaine patches for more than one week without medical consultation 3

Algorithmic Approach to Patch Selection

1. Start with lidocaine 5% patches for most localized pain conditions (neuropathic, myofascial, postherpetic neuralgia) 1
2. Use diclofenac patches for musculoskeletal or bone pain, particularly osteoarthritis 1, 2
3. Consider capsaicin 8% patches only for refractory neuropathic pain unresponsive to lidocaine, with proper medical supervision 7, 5
4. Reserve compounded formulations for complex pain syndromes requiring multi-modal topical therapy 1, 8