Q&A: Topical Analgesics Are Often Underutilized in Pain Management | APhA 2025

Pain management has long been a complex challenge for health care providers, with patients often seeking quick relief from musculoskeletal and nerve-related discomfort. Traditional approaches have typically relied on oral medications, which can expose the entire body to potentially harmful adverse effects. However, emerging medical guidelines are now pointing to a more targeted solution with topical analgesics.

In a recent interview, pain management expert Jeffrey Gudin, MD, faculty in the department of anesthesiology and pain management at the University of Miami, shed light on the growing importance of topical treatments and discussed recommendations from the American College of Physicians and American Academy of Family Physicians. These guidelines suggest that topical analgesics should be the first line of defense for non-low back musculoskeletal pain, marking a significant shift in how clinicians and patients approach pain relief. By offering a localized treatment with minimal systemic absorption, these innovative therapies promise to revolutionize pain management strategies, providing patients with a safer, more precise alternative to traditional oral medications.

Traditional approaches have typically relied on oral medications, which can expose the entire body to potentially harmful adverse effects. | Image Credit: Photo Sesaon | stock.adobe

Drug Topics: How has the topical analgesic landscape evolved in recent years? Are there any emerging trends or new formulations that pharmacists should be aware of?

Jeffrey Gudin, MD: The treatment of painful conditions can be very challenging. We have different types of pain, acute pain and chronic pain, and different causes for pain, musculoskeletal injuries and nerve injuries of the sort, and it's very difficult for patients because we're very limited for the number of therapies that we have. If you think about [it], we have over-the-counter acetaminophen, we have aspirin, and nonsteroidal products, and topical analgesics are used all over the world to treat things like musculoskeletal and nerve pain conditions. Surprisingly, most pharmacists and clinicians aren't aware that a few years ago, there were some guidelines that were published by 2 very prominent medical organizations, the American College of Physicians and the American Academy of Family Physicians, and they looked through all of the available evidence, and they did this review of the literature, a meta-analysis, and what they came up for guidelines with was that if you're going to treat somebody with musculoskeletal pain, let's say non-low back pain musculoskeletal pain, that the first line therapies should be topical analgesics, with or without menthol. So there are guidelines now for patients and clinicians to not reach for a pill or an oral therapy, a systemic therapy, and to use more of a topically applied analgesic.

Drug Topics: What are some common misconceptions patients have about topical analgesics?

Gudin: When I discuss topical analgesics with patients, the first thing they usually say is, "Do those things really work?" And I can tell you, they're proven by literature, and so many patients come back and say it really worked. Now, one of the challenges is there's so many different formulations available. Do we use an anti-inflammatory topical agent? Do we use a local anesthetic topical agent? Do we use a heat-producing agent like capsaicin? And usually what I tell patients is, "Yes, it's worth a try for each one of those." For musculoskeletal pain, I tend to prefer things like methyl salicylate and menthol, the rubiphasins, the topical analgesics that bring heat to the area where we need more blood flow, but some patients don't respond to that. Then I'll say, "Hey, maybe you might want to try a topical agent like lidocaine 4%," which is the maximum allowable concentration available as an over-the-counter topical analgesic product, and oftentimes patients appreciate the warmth or the heat effect of capsaicin, which is known to provide an analgesic benefit when applied topically.

Drug Topics: What are the key differences in systemic exposure and potential adverse effects between topical nonsteroidal anti-inflammatory drugs (NSAIDs) and oral NSAIDs?

Gudin: When we think about [adverse] effects from medications, this is really where topical analgesics shine. If you think about it, taking a pill, your whole body is exposed to that medication just to get it to one little spot, usually where the pain is, and that's why it makes so much sense to try a topically applied analgesic. Why not get the medicine to penetrate the skin and target the area that's affected? When we look at the pharmacokinetic data, the blood supply data, or the blood level data of medications, when you look at topicals, I mean, they're across the board, but it's usually 1/20, 1/50, even 1/100, of the concentration of when we take a full dose by mouth. So it's always, from a safety standpoint, a great place to start with topicals, knowing that they won't get the systemic exposure that they might get from taking a medicine by mouth.

Drug Topics: How can pharmacists effectively counsel patients on the appropriate selection and use of topical analgesics?

Gudin: Pharmacists play a critical role in product selection at the retail level, at the pharmacy level. Patients walk down the aisle, and they're not sure which product to use. Do I use a topical lidocaine product? Do I use a menthol or a methyl salicylate product? Should I try a capsaicin product? So that's where the pharmacist could come in and be helpful. For my patients, historically, I've said, "Well, if you have a neuropathic-like pain, a neurologically induced pain, let's think about lidocaine, a local anesthetic, which is known to work for that kind of pain." But much to my surprise, sometimes patients don't respond with lidocaine, and they'll try one of the others, like a menthol or a capsaicin, and will respond. So the pharmacist plays a critical role in educating patients that it's a trial-by-error for many of these products, but don't give up if one product doesn't work; try another topical analgesic.

Drug Topics: How can pharmacists help patients manage potential adverse effects, such as skin irritation or allergic reactions, from topical analgesics?

Gudin: The most common adverse effects we see with topically applied analgesics are adverse skin reactions. Most of the studies that look at topical analgesics show [adverse] effects comparable to placebo, but if you think about it, you're putting something on the skin, so the most common adverse effect would be a skin irritation. Usually, I counsel patient patients if it's a little bit of redness, try to change the area where you apply it, but if it's anything more than that, I counsel them not to use the product or maybe to find a product that has perhaps a different adhesive or a different delivery system. So instead of a patch, maybe a cream or a roll-on because, when they have an allergy or sensitivity on the skin, it usually doesn't get better by repeat application, so I try to warn them about that.

Drug Topics: How can topical analgesics be used as part of a multimodal approach to pain management, potentially reducing the reliance on opioids?

Gudin: So over the past few decades, the real catchphrase in pain management has been "multimodal analgesia," using smaller doses of different types of medicines to offer patients the best chance of relief with the least amount of [adverse] effects, and this holds true to data, and it makes so much sense to do. We have patients use a topical analgesic first, but that might not be enough for them. We have them spare the medicines that they take, like acetaminophen or NSAIDs [nonsteroidal anti-inflammatory drugs]. And I tell patients that all the time. Look, if wearing this patch allows you to take less pills, and in the old days, especially, that might have meant even opioid pills, that's safe use; that's a rational approach to treating pain, and that's why multimodal therapies are so important. But we have to remember, it's not just drug therapy. We need physical therapy, occupational therapies, behavioral strategies, sleep modification. Sleep is very important for pain, so it's never just a 1-product treatment. We always tell patients about this multimodal therapy in order to give them the best chance of relief.

Drug Topics: Is there anything else you would like to add?

Gudin: I'll remind clinicians that there are guidelines for the treatment of musculoskeletal pain, and those guidelines were pretty clear, after reviewing the literature, that topical analgesic should be tried. First, you get less systemic absorption, less risk of adverse effects, and then if that doesn't work, you can go to your oral medications, hopefully avoiding opioids, and try other interventions as well, like physical therapies, but topical analgesics really should be tried first.

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