New guidelines for acute musculoskeletal pain call for topical NSAIDs and/or menthol: AAFP/ACoP

A new guideline from the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACoP) calls for topical treatment for acute musculoskeletal (MS) pain: topical non-steroidal anti-inflammatory drugs (NSAIDs), possibly in combination with topical menthol.

Two topical NSAIDs are now available. The first, by prescription, has been around for several years: Pennsaid, or 1.5% diclofenac in dimethylsulfoxide (DMSO), a solution that penetrates the skin very readily. This treatment is rapid acting and highly effective. It comes with my personal recommendation, especially for knee and shoulder pain.

It works fast because of its vehicle, DMSO, which has been available for many years. DMSO carries many drugs right through the skin and subcutaneous tissue. Diclofenac, the “active” ingredient, is a potent NSAID that relieves pain and inflammation. When applied topically, its action is limited to the local area and gastrointestinal (GI) side effects are virtually absent (GI effects like stomach pain or even bleeding have always limited the use of NSAIDs, especially aspirin.)

The other topical NSAID is Voltaren Arthritis Pain, or 1% diclofenac gel. This was recently approved for over the counter use and is advertised on TV by Paula Abdul doing a dance that is too frenetic for anyone with arthritis.

A number of non-NSAIDs are also available over the counter. For example, capsaicin (the stuff that makes peppers hot– it directly blocks pain receptors in the skin), Aspercreme (salicylates alone– the active ingredient in aspirin), Ben-Gay (salicylates, camphor, and menthol– the latter being counterirritants), Myoflex (salicylate– a non-greasy form), Sportscreme (salicylate– thicker than average), and Icy Hot (menthol and salicylates). All that from a Healthline web page.

Aspercreme and others are also available with lidocaine (an anesthetic or numbing agent.) This web site says Aspercreme with lidocaine is the best.

The idea behind recommending topical treatment for acute MS pain is that it limits side effects and takes away the onus of “popping pills”– which is arguably a bad habit if you don’t have a serious problem.

Naturally, if you have a significant problem, you are better off consulting a doctor to find out if you have inflammatory arthritis (like rheumatoid arthritis, for example) and need something more effective like a “disease-modifying” drug. NSAIDs merely relieve mild-to-moderate pain and don’t stop deformities, loss of cartilage, or more serious manifestations from appearing.

Take it from me: if you have rheumatoid arthritis, you need to start taking a “disease-modifying” drug before you develop deformities. Don’t wait until you are crippled because those changes are irreversible and just keep getting worse with time. Don’t take cortisone, although it does work; the side effects are even worse than the disease. Try methotrexate or “biologicals”– of which there are at least nine available, each aimed at a different inflammatory process. See this webmd website for more details.

You can review the details of the recommendations for acute musculoskeletal pain due to minor conditions from this article in the Annals of Internal Medicine, published August 18.