Topical NSAIDs

There is evidence that topical NSAIDs are effective in acute soft tissue injury and localised osteoarthritis (OA). The appropriate place in therapy is in acute soft tissue injury or inflammation (strains, sprains, epicondylitis, tenosynovitis), and in localised peripheral OA where pathology is thought to be superficial (such as single joint OA in the hand or knee).

Many products have a licence only for short term use (e.g. ketoprofen). Local concentrations in cartilage and meniscus are several fold that achieved with oral dosing and the long term safety of this has not been established. Synovial fluid concentrations are only half those achieved with oral dosing. Tendon sheath concentrations are several hundred times higher than plasma concentrations after topical administration.

Ibuprofen: please see 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

Diclofenac: please see 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

Ketoprofen: please see 10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

Lidocaine

Emla

(Lidocaine with prilocaine)

• Cream 25mg + 25mg (£2.25 = 5g)

Indications

• Topical anaesthesia of skin
• Neuropathic pain (unlicensed indication)

Notes

1. Prescribe by brand (to aid identification where products contain multiple ingredients, or to prevent confusion where multiple brands contain similar ingredients)
2. May be helpful on sensitive skin

Lidocaine 700mg (5% w/w) medicated plaster

• Medicated plaster (click here for preferred brand)

Indications

• Post-herpetic neuralgia only (see Management of neuropathic pain) (but see notes below)
• Not to be used for non-neuropathic pain e.g. fibromyalgia, musculoskeletal pain, headache etc.

Dose

• Apply to the painful area once daily for up to 12 hours, followed by a 12-hour plaster-free period; plasters may be cut to size if necessary. Up to 3 plasters may be used to cover large areas.
• Review after 2-4 weeks, discontinue if ineffective

Notes

1. Following national guidance from NHS England, not recommended for initiation in primary care. Click here for more information
2. Only recommended for the treatment of post-herpetic neuralgia following initiation by specialist pain team (this may include recommendation to prescribe following outpatient appointment or "advice and guidance" service)
3. Lidocaine plasters are only licensed for use in post herpetic neuralgia; there is a paucity of data from double blind RCTs demonstrating efficacy in other neuropathic conditions.
4. Pain specialists may occasionally recommend a trial of lidocaine plasters in difficult to treat cases of other forms of neuropathic pain. If successful, GPs may continue prescribing with ongoing input from pain specialists. This prescribing remains "off-licence".
5. Lidocaine plasters can result in gradual desensitisation of the nerves, leading to improvement in symptoms; the plaster may be discontinued if this should occur. Prescribers should therefore consider a trial withdrawal of therapy to reassess ongoing need at appropriate intervals e.g. at 3-6 months, and then 6 monthly
6. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Capsaicin

Capsaicin 179mg (8%) patches

• Qutenza self-adhesive patches 179mg (8%)

Indications

• Peripheral neuropathic pain in non-diabetic patients (see below)

Notes

1. Use of capsaicin (8%) patch (Qutenza) for neuropathic pain is commissioned within its licensed indication of peripheral neuropathic pain in non-diabetic patients, only after conventional oral and topical therapies as described in NICE CG96 have proven unsuccessful. Commissioning is restricted to its use in specialist secondary care pain clinics (see Commissioning Policy for more details).