Can lidocaine cream be used for neuropathic pain management?

Lidocaine Cream for Neuropathic Pain

Yes, lidocaine cream can be used for neuropathic pain, but the 5% patch formulation has stronger evidence and guideline support than cream formulations, particularly for localized neuropathic pain conditions. 1, 2

Formulation and Application Guidelines

The most effective lidocaine formulation is the 5% patch (or 4% over-the-counter patch), not cream, applied for up to 12 hours within a 24-hour period with a mandatory 12-hour patch-free interval. 1, 2, 3

• Up to 3 patches can be applied simultaneously to cover the painful area, whether on dorsal or plantar surfaces. 2
• The American Diabetes Association specifically notes that lidocaine patches have limited data supporting their use in diabetic peripheral neuropathy and are not effective for widespread pain distribution. 1
• Lidocaine patches may be particularly useful for patients with nocturnal neuropathic foot pain despite limited overall evidence. 1, 3

Evidence Quality and Efficacy

The evidence supporting lidocaine for neuropathic pain is notably weak:

• A 2014 Cochrane review found no first or second tier evidence (high-quality data) supporting topical lidocaine for neuropathic pain, with all included studies judged at high risk of bias due to small size or incomplete outcome assessment. 4
• Individual studies and clinical experience suggest efficacy in some patients, but robust randomized controlled trial data are lacking. 4
• Real-world evidence from a 2022 German study showed lidocaine 700 mg medicated plaster provided superior pain reduction compared to first-line oral medications in patients with localized peripheral neuropathic pain who were refractory to oral therapy. 5

Specific Indications Where Lidocaine May Be Considered

Lidocaine patches have demonstrated effectiveness in:

• Postherpetic neuralgia: Approximately 60% of patients achieve moderate to complete pain relief with proper 12-hour daily application, with a number needed to treat (NNT) = 2. 2
• Painful diabetic polyneuropathy: Limited data, best for localized nocturnal foot pain. 1, 2
• HIV-associated peripheral neuropathy: Some evidence of benefit. 2

Safety Profile and Advantages

• Minimal systemic absorption, reducing systemic side effects compared to oral medications. 2
• Can be combined with other pain medications for multimodal analgesia. 2
• Long-term use (up to 5 years) shows sustained efficacy without tolerance development, with 40% of initial responders maintaining effective pain relief at 5 years. 6

Important Contraindications and Precautions

• Should not be applied to broken or inflamed skin. 2
• Avoid excessive heat application over treated areas, as this increases systemic absorption. 2
• Contraindicated in advanced liver failure and known hypersensitivity to amide anesthetics. 2
• Monitor for signs of systemic absorption: dizziness, confusion, and bradycardia. 2
• Cannot be used for more than 12 hours in a 24-hour period. 1

When to Choose Alternative Treatments

If lidocaine patches provide insufficient relief or pain is widespread rather than localized, consider:

• Gabapentin: 100-300 mg starting dose, titrated to 900-3600 mg daily. 2
• Pregabalin: 50 mg three times daily, titrated to 100 mg three times daily. 2
• Tricyclic antidepressants (nortriptyline, desipramine): 10-25 mg starting dose, titrated to 50-150 mg. 2
• Capsaicin 8% patch: Can provide pain relief for at least 12 weeks from a single application. 2, 7

Clinical Algorithm

1. Assess pain distribution: Lidocaine is only appropriate for localized neuropathic pain, not widespread distribution. 1, 2
2. Start with 5% lidocaine patch (or 4% OTC formulation) applied for 12 hours daily to the affected area. 2, 3
3. Trial for at least 4 weeks before determining efficacy. 3
4. If inadequate response after 4 weeks, switch to capsaicin 8% patch or initiate oral gabapentinoids or tricyclic antidepressants. 2, 3
5. For widespread pain, skip topical treatments and proceed directly to oral systemic therapies. 1

Common Pitfalls

• Using lidocaine for widespread rather than localized pain—this is ineffective. 1
• Applying patches for longer than 12 hours, which violates FDA guidelines and increases systemic absorption risk. 1, 2
• Expecting robust pain relief based on guideline recommendations when the actual evidence base is weak. 4
• Using cream formulations when patch formulations have better evidence and delivery characteristics. 2, 4