When arthritis pain hits, you might reach for an oral medicine like ibuprofen (Motrin, Advil), naproxen (Aleve), or celecoxib (Celebrex). Those drugs have become popular thanks to their ability to relieve joint pain and reduce inflammation. But because they travel throughout the body they can increase the risks of heart attack, stroke, and gastric irritation or bleeding.
Instead, medicine that you can apply to your skin may have as strong a pain-relieving effect as those of oral nonsteroidal anti-inflammatory drugs (NSAIDs) and may be safer.
It's called diclofenac (Voltaren, Pennsaid). Voltaren gel 1% has been approved by the U.S. Food and Drug Administration for osteoarthritis of the knee and hand; Pennsaid liquid has been approved for knee osteoarthritis. The drugs are added to a “carrier cream” containing nonactive ingredients such as isopropyl alcohol, propylene glycol, and water to help them penetrate the skin.
You gently rub the Voltaren pain cream on the affected area up to four times a day, using a dosing card to dispense a measured amount. With Pennsaid, you apply drops from a liquid formulation to the affected area four times a day or via a spray pump twice a day.
A safer alternative
A topical analgesic can circumvent some serious side effects of oral NSAIDs because it acts directly on the painful joint and tissues through the skin instead of being absorbed through the stomach. Topical diclofenac still enters your bloodstream through the skin but in smaller—and safer—amounts than when taken orally.
According to a review of nearly 40 studies appearing in the April 2016 Cochrane Database of Systematic Reviews, about six in 10 people with osteoarthritis, mostly in the knee, had reduced pain after six to 12 weeks on a topical NSAID.
The average age of the participants in the studies ranged from 59 to 65. The NSAIDs studied included diclofenac, the only pain cream formulation available in the United States.
“Topical NSAIDs are most effective for mild to moderate osteoarthritis in joints close to the skin’s surface—like the hands or knees. They don’t help with deeper joints such as the hip or spine, and they may not be as effective as pills if many of your joints are involved,” says John A. Flynn, M.D., M.Ed., medical director of the Spondyloarthritis Center at Johns Hopkins University School of Medicine in Baltimore. “But because side effects from topical products are generally mild, they can be a safer alternative to oral NSAIDs for some patients.”
A limitation of the Cochrane review was that most of the studies included didn’t perform head-to-head comparisons of topical versus oral NSAIDs. However, in 2006, an Agency for Healthcare Research and Quality review compared both and found that pain relief was similar. Another review last year in Seminars in Arthritis and Rheumatism reached a similar conclusion.
Although rub-on NSAID pain creams tend to be less risky than oral versions, they can cause side effects such as dry skin, redness, rash, burning, and itching at the application site.
Better option for older patients
Topical NSAID pain creams for daily use may be a better option than oral for people who are older, especially patients ages 75 and above; take warfarin, a daily low-dose aspirin, or another anticlotting drug; have a history of peptic ulcers; or otherwise can’t tolerate oral NSAIDs.
The American College of Rheumatology recommends topical NSAIDs for knee osteoarthritis in people older than 75 who are at high risk for NSAID-related complications. Topical NSAIDs are ideal for individuals at risk for gastrointestinal, cardiovascular, and other side effects associated with NSAIDs. Others may simply prefer the topical option because it can bring faster relief.
Over-the-counter pain cream treatments
Voltaren and Pennsaid are available by prescription only. If you’d rather not use an NSAID to ease your discomfort, several over-the-counter topical arthritis pain creams are available. They come in creams, gels, patches, and ointments:
• Capsaicin (Capzasin, Zostrix) is the same substance that gives you a burning sensation when you eat chili peppers. You may feel a slight burn when you rub it on, and your skin may turn red.
• Salicylates (Aspercreme, BenGay, Flexall, Sportscreme) work in the same way as aspirin. Because some of the medicine gets absorbed into the skin, topical salicylates might not be a good option for people who are sensitive to aspirin or taking drugs that might interact with aspirin.
• Counterirritants (Biofreeze, Icy Hot, BenGay) contain ingredients like menthol, camphor, eucalyptus oil, and turpentine oil. They create a warming or cooling sensation that distracts from arthritis pain. The main side effect is redness of the skin, which is usually temporary.
Using topical pain creams safely
Though it’s rare, some nonprescription topical medicines that contain menthol or methyl salicylate, including BenGay, Icy Hot, and Capzasin, can cause serious burns. To reduce your injury risk:
• Don’t use tight wraps or bandages on the area after applying the medicine.
• Don’t use heating pads, heat lamps, or other sources of added heat.
• Avoid applying the medicine to damaged or broken skin or areas close to your eyes, nose, or mouth.
• Wash your hands after applying the pain cream, unless you’re treating your hands. In that case, wait at least an hour before washing your hands.
• Don’t use topical pain relievers more than three or four times a day.