What topical treatments are available for neuropathy in the feet?

Topical Treatments for Foot Neuropathy

For localized neuropathic foot pain, start with capsaicin 0.075% cream applied 3-4 times daily, or consider the high-concentration 8% capsaicin patch for more severe pain requiring office-based application under medical supervision. 1, 2, 3

First-Line Topical Options

Low-Concentration Capsaicin Cream (0.075%)

• Apply a thin film to affected areas 3-4 times daily, rubbing in until fully absorbed 3
• Requires consistent application for at least 6-8 weeks to assess true efficacy 2, 4
• Approximately 75% of patients experience improvement with regular use 2
• Initial burning sensation is expected and typically resolves after several days of continued use 1, 2
• Works by depleting substance P from nerve terminals, causing desensitization of pain receptors 1
• Wash hands thoroughly immediately after application unless treating the hands themselves 3
• Avoid contact with eyes, mucous membranes, and genitalia as capsaicin is a potent local irritant 2, 4

High-Concentration Capsaicin 8% Patch (Qutenza)

• FDA-approved specifically for diabetic peripheral neuropathy with the strongest evidence for efficacy 2, 4
• Must be applied under medical supervision for 30-60 minutes (30 minutes for diabetic neuropathy, 60 minutes for postherpetic neuralgia) 2, 4
• Provides sustained pain relief lasting up to 12 weeks from a single application 2, 5, 6
• Mandatory pretreatment with topical lidocaine 4% for 60 minutes before patch application to reduce discomfort 2, 4
• Consider prescribing short-acting opioids or acetaminophen for use during and up to 7 days after application for breakthrough pain 2, 4
• 31% of patients achieve >30% pain reduction compared to 14% with placebo in neuropathy studies 2, 4
• Can be reapplied every 90 days if pain returns 2

Lidocaine 5% Patches

• Apply up to 3 patches to affected feet for up to 12 hours, particularly useful for nighttime pain 4, 7
• Best suited for localized pain rather than widespread neuropathy 4
• No systemic absorption or toxicity reported with proper use 4
• Over-the-counter 4% formulations available, though prescription 5% may be more effective 4

Treatment Algorithm

Step 1: For mild-to-moderate localized foot neuropathy, begin with capsaicin 0.075% cream applied 3-4 times daily 1, 2, 3

Step 2: If inadequate response after 6-8 weeks or patient prefers less frequent application, consider capsaicin 8% patch applied in-office 2, 4

Step 3: For predominantly nighttime symptoms, add or switch to lidocaine 5% patches applied before sleep 4, 7

Step 4: If topical treatments provide insufficient relief, combine with oral agents (pregabalin, duloxetine, or gabapentin) rather than abandoning topical therapy 1, 2

Critical Application Details for Capsaicin 8% Patch

Pre-Application Protocol

• Mark the most painful areas on intact skin before starting 2, 4
• Apply topical lidocaine 4% for exactly 60 minutes before capsaicin patch—this is the most critical step for tolerability 2, 4
• Healthcare staff must wear gloves throughout the entire procedure to avoid unintentional contact 2, 4

During Application

• Leave patch in place for 30 minutes for diabetic neuropathy (60 minutes for postherpetic neuralgia) 2, 4
• Monitor patient for tolerability and provide additional analgesics if needed 2, 4

Post-Application Care

• Cleanse area thoroughly after patch removal 2
• Warn patients about potential increased pain for up to 7 days post-application 2, 4
• Schedule follow-up at 2-4 weeks to assess early response 2

Important Clinical Considerations

Patient Selection for Topical Therapy

• Best suited for localized neuropathic pain affecting specific areas of the feet 1, 4
• Ideal for patients with contraindications to oral medications (e.g., hepatic disease, cardiac disease, orthostatic hypotension) 1
• Preferred by patients wanting to avoid systemic side effects such as sedation, weight gain, or dizziness 1, 4

Common Pitfalls to Avoid

• Do not skip lidocaine pretreatment for the 8% patch—this is the most common cause of poor tolerability 2, 4
• Do not discontinue capsaicin cream prematurely—patients must use it consistently for 6-8 weeks before declaring failure 2, 4
• Do not expect immediate pain relief—capsaicin requires days to weeks of consistent use to achieve benefit 2, 4
• Do not use high-dose vitamin C supplements with capsaicin in chemotherapy-induced neuropathy, as it may interfere with treatment efficacy 1
• Avoid inadequate pain management during 8% patch application—have rescue analgesics readily available 2, 4

Expected Adverse Effects

• Local skin reactions (erythema, burning) are common with capsaicin but usually mild and transient 1, 8, 5
• Number needed to harm is 2.5 for local reactions with low-dose capsaicin cream 4, 8
• Serious systemic adverse events are rare (4.1% with active treatment vs 3.2% with control) 5
• Initial burning sensation typically resolves after several days of regular capsaicin cream use 2, 4

When Topical Therapy May Be Insufficient

• Patients with severe, widespread neuropathy affecting large areas beyond the feet 4
• Those with pain duration >2-3 years tend to respond less well to topical treatments 4
• Patients requiring >50% pain reduction may need combination therapy with oral agents 1, 2

Emerging Evidence on Disease Modification

Recent research suggests that capsaicin 8% patch may promote nerve fiber regeneration in addition to providing pain relief 9. In chemotherapy-induced neuropathy, post-treatment biopsies showed significant increases in intra-epidermal nerve fibers (p=0.009), heat receptor TRPV1 (p=0.027), and regenerating nerve marker GAP43 (p=0.04) 9. This suggests potential disease-modifying effects beyond symptomatic relief, though this requires further validation in diabetic neuropathy 9.

Combination with Non-Pharmacologic Measures

Complement topical treatments with practical foot care measures 1:

• Wear loose-fitting shoes, roomy cotton socks, and padded slippers 1
• Keep feet uncovered in bed to avoid pressure on toes 1
• Walk regularly to improve circulation, but avoid excessive standing 1
• Soak feet in cold water and massage for temporary additional relief 1