10.3.2 Rubefacients, topical NSAIDs, capsaicin, and poultices

ChoiceDrugDosage
1st choicePiroxicam 0.5% gel 60g, 112gDose:
Apply 3-4 times daily

Prescribing Notes

  • Topical NSAIDs may be considered as additional pain relief for people with knee or hand osteoarthritis. Topical NSAIDs should be considered before oral NSAIDs.
  • All topical NSAIDS are considered equally efficacious.
  • Topical preparations containing piroxicam are not affected by the EMEA restrictions on the use of piroxicam.
  • Patients should be advised against excessive exposure to sunlight of area treated in order to avoid possibility of photosensitivity.
  • The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.
  • Evidence to support the use of use of topical capsaicin is limited.
  • A preparation containing capsaicin 0.025% (Zacin® cream) can be considered as an adjunct in hand or knee osteoarthritis. It may need to be used for 4 weeks before pain is relieved; pain relief usually starts within the first week of treatment and increases with continuing regular application (four times daily). Stop if ineffective after being used correctly for 4-6 weeks.
  • A capsaicin 0.075% cream (Axsain®) is licensed for the symptomatic relief of postherpetic neuralgia after lesions have healed, and for the relief of painful diabetic neuropathy. Capsaicin 0.075% cream requires specialist input for application in painful diabetic neuropathy.
  • Kaolin poultices are not recommended for prescribing on the NHS.