What is the treatment for topical pain using cream?

From the Guidelines

For the management of pain, particularly neuropathic pain, capsaicin cream is a recommended topical treatment option, as evidenced by recent studies 1. When considering pain creams for localized pain relief, several options are available, including over-the-counter and prescription medications.

• For mild to moderate pain, over-the-counter options include menthol-based products like Biofreeze or IcyHot (2-10% menthol), which create a cooling sensation that distracts from pain.
• Capsaicin creams (0.025-0.1%) derived from chili peppers can help with arthritis or neuropathic pain but may cause initial burning sensations, as noted in studies 1.
• NSAIDs in topical form, such as diclofenenac gel (1-2%), provide anti-inflammatory effects with fewer systemic side effects than oral medications.
• For more severe pain, prescription options include compounded creams containing combinations of medications like lidocaine (2-5%), ketamine (5-10%), gabapentin (6%), amitriptyline (2%), and others tailored to specific pain conditions. The application of these creams should be done 3-4 times daily to clean, dry skin, using only the recommended amount and washing hands after application, as advised in the management of chronic pain 1. These topical treatments work by either blocking pain signals locally, reducing inflammation, or creating counter-irritant sensations that override pain perception, making them particularly useful for joint pain, muscle soreness, and some neuropathic conditions, as supported by the evidence 1.

From the FDA Drug Label

Apply a thin film of cream to affected area and gently rub in until fully absorbed. Apply diclofenac sodium topical solution evenly around the front, back, and sides of your knee. Unless treating hands, wash hands thoroughly with soap and water immediately after application. The answer to the question about pain cream is that there are different types of pain creams, including diclofenac, capsaicin, and lidocaine, each with its own application instructions.

• Diclofenac should be applied evenly around the front, back, and sides of the knee, without massaging the knee.
• Capsaicin should be applied as a thin film to the affected area and gently rubbed in until fully absorbed.
• Lidocaine is a maximum strength external analgesic that helps to numb away pain, but its application instructions are not fully described in the provided text 2, 3, 4.

From the Research

Overview of Pain Cream

• Pain creams, such as those containing capsaicin, are used to treat pain from a wide range of chronic conditions, including neuropathic pain 5, 6, 7.
• Capsaicin causes enhanced sensitivity to noxious stimuli, followed by a period with reduced sensitivity and, after repeated applications, persistent desensitisation 5, 6, 8.

Efficacy of Capsaicin Cream

• The efficacy of low-concentration capsaicin cream in treating neuropathic pain is uncertain, with some studies suggesting it may be without meaningful effect beyond that found in placebo creams 5.
• High-concentration capsaicin patches may provide a degree of pain relief to some patients with painful neuropathic conditions, with a number needed to treat for an additional beneficial outcome (NNT) of 8.8 for postherpetic neuralgia 8.
• Topical capsaicin has been shown to be effective in the treatment of patients with chronic soft-tissue pain and neuropathic pain, including postherpetic neuralgia and diabetic peripheral neuropathic pain 6, 9.

Safety and Tolerability

• Local skin reactions, such as irritation and burning, are common with capsaicin cream, but are usually tolerable and attenuated with time 5, 6, 8.
• Systemic adverse effects are rare, and serious adverse events are no more common with active treatment than control 8.
• The quality of the evidence for efficacy outcomes is moderate or very low, due to sparse data, imprecision, and possible effects of imputation methods 8.

Comparison to Other Therapies

• High-concentration topical capsaicin is similar in its effects to other therapies for chronic pain, and may offer a safe, well-tolerated, and effective alternative to systemic therapies 9, 8.
• Capsaicin has great potential for becoming a first- or second-line treatment for neuropathic pain, and for becoming a therapeutic option for many other neuropathic pain-related disease states 7.