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Get rub-on relief for arthritis joint pain

JAN 2013

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Anti-inflammatory medications applied to the skin as creams, gels, sprays, or patches work best for mild to moderate pain near the surface.

Do you have mild to moderate osteoarthritis, or perhaps a sore shoulder or throbbing elbow from yard work? If the source of the pain is close to the surface, you should know about topical analgesics.

Topical analgesics are pain relievers applied to the skin instead of taken as pills or liquids. Prescription versions come as creams, sprays, gels, or patches. The active ingredients, nonsteroidal anti-inflammatory drugs (NSAIDs), soak in through the skin to reach the pain. In contrast, oral pain relievers flood the whole body with the medication.

The source of the trouble largely determines who can benefit from topical pain relievers. "They can be very helpful for the more superficial joints like the knees, ankles, feet, elbows, and hands," says Dr. Rosalyn Nguyen, a clinical instructor in physical medicine and rehabilitation at Harvard Medical School. "In those areas, the medication can penetrate closer to the joint."

NSAID targeting

There are about 20 NSAIDs available, including over-the-counter versions of ibuprofen (Advil, Motrin), and naproxen (Aleve).
For many people with osteoarthritis, NSAIDs are more effective than acetaminophen (Tylenol) because they target inflammation, which contributes to pain, swelling, and stiffness.

When taken by mouth, as a pill or liquid, the NSAID is absorbed in the gastrointestinal tract. Then the drug travels in the bloodstream toward the source of the pain. But the blood also carries it to places that don't need it. For example, an NSAID can cause stomach upset or even bleeding or ulcers.

Applying a topical NSAID concentrates the medicine near the pain site. But a small amount does still enter the bloodstream. For this reason, topical NSAIDs may be off-limits to people at high risk for side effects. This would include people with a history of ulcers or gastrointestinal bleeding. "I would still be reluctant to use an NSAID, although the risk would be much less than it would be with oral formulations," Dr. Nguyen says.

Are topical pain relievers for you?

Dr. Nguyen says that many people who ask her about topical NSAIDs are looking for ways to avoid adding new pills—and side effects. "Mostly they want to avoid the interactions of medications," she says. "Some people really don't want to be taking pills, or have trouble swallowing them."

The ability to target pain more precisely helps to skirt the side effects of oral drugs. "If it's a localized problem, with just one joint causing the pain, then there's no need for a medication to travel throughout the body," Dr. Nguyen says. If the pain affects an extended area, like the lower back, or affects more than one part of the body, topical pain relievers may not be the best choice.

How well do they work?

A recent scientific review by the Cochrane Collaboration, an international body of health experts, found that some prescription topical NSAIDs
offer the same pain relief as oral medications, but with fewer gastrointestinal concerns.

The Cochrane review covered 34 studies involving 7,688 adults who experienced chronic musculoskeletal pain for at least three months. They received several different kinds of topical NSAIDs for their pain. The topical NSAID diclofenac (Voltaren) was as effective as oral NSAIDs for arthritis in the knee or hand.

Over-the-counter topical pain relievers

  • Counterirritants: These products (such as Icy Hot and Bengay) contain ingredients like menthol, eucalyptus, and camphor oil, which temporarily mask the underlying pain with a sensation of coolness or heat. Some counterirritants also contain salicylates, a type of chemical similar to aspirin that has a milder anti-inflammatory effect.

  • Capsaicin: These products (such as Zostrix) contain capsaicin, which is the stuff that makes hot peppers so fiery. Rubbing them on the skin overloads the pain sensing circuits. Capsaicin causes burning pain when it contacts your eyes or mouth, so use care when applying these products. Don't use if you are allergic to hot peppers.

Limits on use of topicals

Applied as directed, two to four times a day, topical NSAIDs can control mild to moderate pain. For severe (bone-on-bone) osteoarthritis, topical options probably can't match larger doses of oral medications. Still, even in these cases, a topical drug could help.

"I will recommend it even if the pain is severe in a superficial joint, on the chance it will help to reduce any portion of the pain," says pain specialist Dr. Joanne Borg-Stein, medical director of the Harvard-affiliated Spaulding-Wellesley Rehabilitation Center in Massachusetts. (Don't combine oral and topical NSAIDs—prescription or over-the-counter—without telling your doctor, however.)

Availability and cost may limit the use of topical NSAIDs for some people. In the United States, the only prescription topical NSAID widely available in pharmacies is diclofenac gel. Other types, such as ibuprofen, ketoprofen (Orudis), indomethacin (Indocin), and piroxicam (Feldene) may require a special order from a compounding pharmacy. This could raise the
price, and insurance reimbursement varies according to the type of topical formulation prescribed.

Most benefit if:

  • your stomach is sensitive to NSAIDs

  • the source of pain is near the surface

  • the pain comes from a focused area, such as a single joint.

Less benefit if:

  • you have active ulcers

  • you have a history of gastrointestinal bleeding

  • you have severe pain.

Possible side effects

Adverse side effects from topical medications are mild and uncommon. They usually include redness, itching, and other skin irritation. Dr. Borg-Stein says that when her patients experience skin irritation, the cause is often the material used to make the cream or gel. In these cases, a pharmacist can create a topical preparation with ingredients that are less irritating to your skin.

A key safety tip for all topical drugs is to wash your hands thoroughly after use so that you don't smear the drug into your eyes, nose, mouth, or other mucous membranes.