What Are Topical Treatments?
Topical treatments are applied directly to the skin over painful joints. They work locally, delivering medication to the affected area with less absorption into your bloodstream than oral medications. This can mean fewer side effects while still providing meaningful pain relief.
Topical treatments work best for joints close to the skin surface, like knees, hands, and elbows. They’re less effective for deeper joints like hips or spine.
Types of Topical Treatments
Topical NSAIDs
The most evidence-supported topical option for arthritis.
Diclofenac Gel (Voltaren Arthritis Pain)
- Now available over-the-counter
- Apply 4 times daily (2g per knee, 2g upper extremity)
- Proven effective for knee and hand osteoarthritis
- 40-50% less GI risk than oral NSAIDs
- May cause skin irritation at application site
Diclofenac Solution (Pennsaid)
- Prescription liquid applied with pump
- 1.5% or 2% strength available
- Often covered by insurance
- Apply 2-4 times daily depending on formulation
Topical Ibuprofen/Ketoprofen
- Available in some countries, limited US availability
- Compounding pharmacies may prepare custom formulations
- Less research than diclofenac
Capsaicin
Derived from chili peppers, capsaicin works by depleting substance P, a pain-signaling chemical.
How to Use
- Apply 3-4 times daily for best results
- Takes 2-4 weeks of regular use to work
- Initial burning sensation is normal (diminishes over time)
- Wash hands thoroughly after application
- Avoid contact with eyes and mucous membranes
Available Strengths
- 0.025% - Starting strength
- 0.075% - Higher strength
- 0.1% - Maximum OTC strength
- 8% (Qutenza) - Prescription patch for nerve pain
Effectiveness
- Modest pain relief (20-30% reduction)
- Works better with consistent, long-term use
- Good option when other topicals cause irritation
Counterirritants
These create sensations that mask pain.
Menthol Products (Bengay, Icy Hot, Biofreeze)
- Creates cooling sensation
- Temporary relief (1-2 hours)
- No disease-modifying effect
- Useful for quick relief before activities
- Available in various forms: creams, gels, sprays, patches
Camphor Products
- Warming sensation
- Often combined with menthol
- Short-acting relief
- Can cause skin irritation with excessive use
Methyl Salicylate (Wintergreen)
- Aspirin-like compound
- Provides warmth and mild anti-inflammatory effect
- Caution: Can be toxic if overused or in children
- Don’t use with blood thinners
Lidocaine
A local anesthetic that numbs pain nerves.
Lidocaine Patches (Lidoderm)
- Prescription strength (5%)
- Apply to painful area for up to 12 hours
- FDA-approved for nerve pain, used off-label for arthritis
- Often covered by insurance
- Maximum 3 patches at a time
OTC Lidocaine Products
- 4% strength (creams, patches, sprays)
- Aspercreme with Lidocaine, Salonpas
- Shorter-acting than prescription patches
- No prescription needed
Compounded Topicals
Custom-mixed formulations combining multiple ingredients:
- May include: ketoprofen, gabapentin, baclofen, cyclobenzaprine
- Prepared by compounding pharmacies
- Limited insurance coverage
- Variable quality control
- Research on effectiveness is limited
Evidence: What Works Best?
Strong Evidence
- Topical diclofenac for knee and hand osteoarthritis
- Capsaicin for osteoarthritis (with consistent use)
Moderate Evidence
- Topical lidocaine for localized pain
- Topical NSAIDs for other joints near skin surface
Limited Evidence
- Menthol/camphor products (temporary relief only)
- Compounded topicals (lack standardized research)
How to Use Topical Treatments Effectively
Application Tips
- Clean the area before applying
- Use the right amount - follow package directions
- Rub in thoroughly until absorbed
- Wash hands after application (unless treating hands)
- Don’t cover with tight bandages unless directed
- Be consistent - most work better with regular use
- Allow time - some take weeks to show full effect
Getting the Most Benefit
- Apply before activities that cause pain
- Combine with other treatments (PT, bracing)
- Give it time (2-4 weeks for full effect)
- Don’t expect complete pain elimination
- Use as part of a comprehensive plan
Safety Considerations
General Precautions
- Don’t apply to broken or irritated skin
- Avoid contact with eyes, mouth, and sensitive areas
- Don’t use with heating pads (increases absorption)
- Check for allergies to ingredients
- Don’t use multiple topical products on the same area
Who Should Be Careful
- Aspirin allergies: Avoid methyl salicylate products
- Blood thinners: Avoid aspirin-related products
- Sensitive skin: Start with lower concentrations
- Multiple medications: Check for interactions
Side Effects
Common:
- Skin irritation or redness
- Burning or stinging sensation
- Dry skin at application site
Less Common:
- Allergic reactions
- Photosensitivity (increased sun sensitivity)
- Systemic absorption (rare with proper use)
Comparing Topical Options
| Product Type | Best For | Onset | Duration | Cost |
|---|---|---|---|---|
| Diclofenac gel | Knee/hand OA | 1-2 weeks | Ongoing use | $15-30 OTC |
| Capsaicin | Chronic pain | 2-4 weeks | Ongoing use | $8-15 |
| Menthol | Quick relief | Minutes | 1-2 hours | $5-15 |
| Lidocaine | Localized pain | 30 min | 4-12 hours | $10-50 |
Insurance Coverage
OTC Products
- Generally not covered by insurance
- HSA/FSA eligible
- Generic versions often available
Prescription Products
- Topical diclofenac (Pennsaid): Often covered with prior auth
- Lidocaine patches: May require prior authorization
- Compounded topicals: Rarely covered
- Check formulary for preferred products
Questions to Ask Your Healthcare Provider
- Which topical treatment is best for my specific condition?
- Can I use topical NSAIDs if I can’t take oral NSAIDs?
- How long should I try a topical before deciding if it works?
- Can I use topical treatments along with my oral medications?
- Are there prescription topicals that might work better for me?
- How do I know if I’m having a reaction to the medication?