Topical Analgesics

When the patient has a specific tender point or has an area of pain that is limited, it is tempting to use a type of pain relief that will affect only the painful area. The lidocaine patch is a soft flannel-backed patch with 5% lidocaine that can be applied over the painful area. It has an indication for use with postherpetic neuralgia and has been studied in painful diabetic neuropathy, complex regional pain syndrome, postmastec-tomy pain, and HIV-related neuropathy (APS, 2008).

The patch is designed to be used for 12 hours on and 12 hours off, although patients have worn the patch for 24 hours with no ill effects (APS, 2008; D'Arcy, 2007). The maximum dose of Lidoderm is up to three patches at one time. The patches should be replaced daily and placed only on intact skin. Active serum levels of lidocaine with patch use are minimal (APS,2008). Patients tolerate this type of therapy very well, and, because it is noninvasive, if the patient does not like the feeling of the patch or effect, the patch can be easily removed. The one side effect from the Lidoderm patch that has been reported is skin irritation at the site of patch application.

■ Capsaicin Cream (Zostrix)

This topical cream that can reduce the secretion of substance P at peripheral nerve ending is derived from hot peppers and is called capsaicin. It is sold over the counter in two different strengths as a generic brand or Zostrix cream. The neuropathic conditions for which this cream has been most helpful include postmastectomy pain, other peripheral neuropathic conditions, and neck and arthritis pain (APS, 2008).

When the cream is applied, it causes a burning sensation in the application area. Patients should be warned to expect the sensa tion. Gloves should be used to apply the cream and other parts of the body, such as the eyes, should not be touched until all the cream is removed from the hands. Use of this technique requires a dedicated patient who is willing to persevere and apply the cream three to four times per day for 2 weeks to see if there is any analgesic benefit.

The newest use of capsaicin is a concentrated 8% patch (Qutenza) for postherpetic neuralgia that needs to have a local anesthetic applied at the site of patch placement prior to the placement. The patch is left in place for 1 hour, and then removed. This is a technique that requires a health care provider for application. Studies have shown improved pain relief with patch applications and extended effect with sustained pain relief for up to 12 weeks. Certainly, this not a common use for capsaicin, but for the select few who need it, the technique can provide improved pain relief (Dworkin et al., 2010).

Targeted Analgesic-Diclofenac Epolamine Patch (Flector)

Thie Flector Patch is a nonselective NSAID patch that is applied directly over the site of the pain on intact skin. It is especially useful for strains and sprains. The recommended dose is one patch to the affected area twice daily (Nursing 2010 Drug Handbook, 2009). Because this is a new use for NSAIDs, the research support is limited, and data on systemic absorption are open to change when clinical usage increases. Currently, the medication has the same black box warning as all nonselective NSAIDs.

Thiere are compounded gels and over-the-counter NSAID gel and liquid formulations as well. These can be very effective if used as directed in the prescribed area. However, with continued use and application over large areas, there is an increased potential for systemic absorption. Patients are advised to use the application card supplied with the medication and to wear gloves when applying the gel (Nursing 2010 Drug Handbook, 2009).

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