How to Prescribe Diclofenac Gel
Indication-Specific Prescribing
The prescribing of diclofenac gel depends entirely on the indication: for actinic keratosis, prescribe 3% diclofenac in 2.5% hyaluronic acid gel applied twice daily for 60-90 days; for musculoskeletal pain, prescribe diclofenac sodium topical solution 1-2% applied to the affected area 2-4 times daily. 1, 2, 3
For Actinic Keratosis
Formulation and Dosing
- Prescribe 3% diclofenac sodium in 2.5% hyaluronic acid gel (Solaraze) 1, 2
- Apply 0.5g twice daily to each 5cm x 5cm treatment area 4
- Treatment duration: 60-90 days 5, 1, 2
- Extending treatment beyond 90 days to 180 days provides only an additional 5% complete clearance without significant benefit 1, 2
Application Instructions
- Apply to clean, dry skin 3
- Spread evenly over the entire treatment field 4
- Wash hands completely after application 3
- Avoid showering/bathing for at least 30 minutes after application 3
Site-Specific Considerations
- Face and scalp: Standard twice-daily application for 60-90 days 1
- Forearms and hands: May require prolonged treatment due to thicker keratin 1
- Below the knee: Use with extreme caution due to poor healing potential; consider less frequent application or alternative treatments 5, 1
Expected Efficacy
- Complete clearance rates range from 19-50% after 90 days 1, 2
- 50% of patients achieve complete clearance with 90-day treatment versus 20% with vehicle alone 5, 2
- 70% of target lesions resolve after 60 days versus 44% with vehicle 5, 2
Patient Counseling
- Diclofenac causes less intense local skin reactions than 5-fluorouracil or imiquimod, making it more tolerable but potentially less effective 1, 2
- Most common side effects are pruritus (41%) and rash (40%) 5
- Patients should expect gradual improvement, with assessment 30 days after completing treatment 4
For Musculoskeletal Pain (Osteoarthritis, Acute Injuries)
Formulation and Dosing
- Prescribe diclofenac sodium topical solution 1.5% or 2% 3
- For knee osteoarthritis: 40mg (2 pump actuations) per knee, twice daily 3
- For acute musculoskeletal injuries: Apply to affected area 2-4 times daily 6
Application Instructions
- Prime the pump before first use by fully depressing 4 times (discard this portion) 3
- Dispense directly onto the affected area or into the hand first, then apply 3
- Spread evenly around front, back, and sides of the joint 3
- Wash hands completely after application 3
- Wait until the area is completely dry before covering with clothing (avoid skin-to-skin contact with others until dry) 3
- Avoid showering/bathing for at least 30 minutes after application 3
Safety Precautions
- Do not apply to open wounds 3
- Avoid contact with eyes, nose, and mucous membranes 3
- Do not apply external heat or occlusive dressings 3
- Protect treated area from natural and artificial sunlight 3
- Wait until dry before applying sunscreen, insect repellent, or other topical products 3
Comparative Advantages
- Topical diclofenac provides equivalent pain relief to oral NSAIDs but with 5- to 17-fold lower systemic exposure 7
- Markedly fewer gastrointestinal adverse events compared to oral NSAIDs 6, 7
- Preferred for elderly patients (≥75 years) and those with increased risk of renal adverse events 6
First-Line Recommendation
- The American College of Physicians and American Academy of Family Physicians recommend topical NSAIDs (including diclofenac) as first-line therapy for acute musculoskeletal injuries 6
- Topical diclofenac with or without menthol gel provides superior pain relief compared to placebo 6
Critical Safety Warnings
Cardiovascular Risk
- Diclofenac may increase the risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke 2
- Patients with cardiovascular disease or risk factors are at increased risk 2
Combination Therapy
- Do not use combination therapy with topical and oral NSAIDs unless the benefit outweighs the risk 3
- If combined therapy is necessary, conduct periodic laboratory evaluations 3
Use Lowest Effective Dose
- Use the lowest effective dosage for the shortest duration consistent with treatment goals 3
Common Pitfalls to Avoid
- Do not prescribe diclofenac gel for actinic keratosis below the knee without careful consideration of healing risks 5, 1
- Do not expect immediate results for actinic keratosis—assessment should occur 30 days after completing treatment 4
- Do not combine diclofenac with cryosurgery for actinic keratosis—no added benefit 1
- Do not apply more than the recommended dose—exceeding dosage has not been studied 3