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10.3.2 Rubefacients, topical NSAIDs, capsaicin, and poultices

1st choiceIbuprofen 5% gel

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.
  • 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.  NICE also recommend capsaicin 0.075% cream for people with localised neuropathic pain who wish to avoid, or cannot tolerate, oral treatments – see 4.7.3
  • Kaolin poultices are not recommended for prescribing on the NHS.


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