When your knee aches after walking, your shoulder stiffens from arthritis, or nerve pain from shingles keeps you awake at night, swallowing a pill isn’t always the best answer. That’s where topical analgesics come in - gels, patches, and creams applied directly to the skin to block pain where it happens, without flooding your whole body with drugs.
How Topical Analgesics Work (Without the Side Effects)
Oral painkillers like ibuprofen or oxycodone get absorbed into your bloodstream and travel everywhere. That’s how they help your pain - but also how they cause stomach upset, liver stress, kidney strain, or drowsiness. Topical analgesics are different. They stay mostly where you put them. The skin acts like a barrier, letting just enough medicine through to calm local nerves while keeping the rest out of your system. This makes them ideal for people who can’t take oral NSAIDs because of ulcers, high blood pressure, or kidney issues. It’s also why they’re so popular among older adults. In 2022, nearly half of Medicare beneficiaries used a topical pain reliever for osteoarthritis - far more than younger adults. There are three main types you’ll find in pharmacies and clinics: lidocaine patches, capsaicin products, and NSAID gels. Each works in a completely different way.Lidocaine Patches: Numbing the Nerves
Lidocaine is a local anesthetic you’ve probably heard of from dentist visits. In patch form - like Lidoderm® - it’s delivered through the skin at a steady, low dose. The 5% patch is FDA-approved for postherpetic neuralgia (nerve pain after shingles), but many use it for other localized nerve pain or muscle soreness. It doesn’t reduce inflammation. Instead, it blocks sodium channels in nerve endings, stopping pain signals before they reach your brain. Think of it like cutting the wire to a buzzer - the buzzer’s still there, but it can’t ring. You can wear up to three patches at once, but only for 12 hours, then take them off for 12 hours. This isn’t just a suggestion - it’s built into the drug’s design. Applying more or longer won’t help and might cause skin irritation or, rarely, heart rhythm issues. Studies show it helps about 1 in 7 people with nerve pain (NNT of 6.7). That’s not as strong as some pills, but it’s much safer. No dizziness. No constipation. No risk of addiction. And plasma levels stay below 10% of the dangerous threshold.Capsaicin: Burn to Block
Capsaicin comes from chili peppers. Yes, the same thing that makes your tongue feel like it’s on fire. But in high concentrations - like the 8% patch called Qutenza® - it does something surprising: it burns your nerves into submission. When you first apply it, TRPV1 receptors on pain nerves get activated. That triggers a rush of calcium and sodium, causing intense burning, stinging, or itching. It’s not pleasant - 30% to 50% of people quit because of it. But within 30 to 60 minutes, those nerves start to shut down. They stop sending pain signals. For weeks. This isn’t a daily cream. The 8% patch is applied only once every 90 days, and only by a trained professional. Why? Because it’s potent. It can damage eyes or mucous membranes if it gets there. And it’s not cheap - it costs hundreds of dollars per application. But for postherpetic neuralgia, it works better than many oral drugs. One study found NNT of 4.4 - meaning 1 in 4 people got major relief. That’s better than gabapentin or pregabalin, with fewer side effects like drowsiness or weight gain. Over-the-counter capsaicin creams (0.025% to 0.1%) are milder. They work too, but you have to use them 3-4 times a day for weeks before you feel any benefit. Many people give up before then.NSAID Gels: Fighting Inflammation at the Source
If your pain comes from swelling - like arthritis in your knee or a sprained ankle - NSAID gels are often the first choice. Diclofenac (Voltaren®), ibuprofen, and ketoprofen gels work by blocking COX enzymes right where the inflammation is. Unlike oral NSAIDs, which get absorbed into your blood and then travel to the joint, topical NSAIDs build up in the tissue under your skin. Microdialysis studies show concentrations 10 to 100 times higher in the joint than in your bloodstream. That means you get the pain relief without the stomach bleeding or heart risks. For knee osteoarthritis, clinical trials show 60% of users get at least 50% pain reduction in four weeks. For hips? Only 20%. That’s because the hip is deep. Topical gels only penetrate about 5-10 millimeters - enough for knees, elbows, wrists, and ankles, but not shoulders or hips. You apply it 4 times a day, usually a 2-4 inch ribbon each time. Most people don’t use enough. One survey found 60% of first-time users apply less than half the recommended amount. Massage it in gently - don’t rub it in like you’re waxing your car. Wait 30-45 minutes before washing your hands or showering. The FDA requires a warning on all topical NSAIDs about cardiovascular risk, but the actual risk is tiny compared to pills. A 2018 Cochrane review found gastrointestinal side effects were just 0.03% with gels versus 1.5% with oral NSAIDs.
Who Benefits Most - and Who Should Avoid Them
These aren’t magic bullets. They work best for surface-level, localized pain. Here’s who they help most:- People with osteoarthritis in knees, hands, or elbows
- Those with nerve pain from shingles (postherpetic neuralgia)
- Patients with muscle strains or tendonitis
- Elderly people on multiple medications (fewer drug interactions)
- Anyone with stomach ulcers, kidney disease, or heart issues who can’t take oral NSAIDs
- People with open wounds, rashes, or broken skin at the application site
- Those allergic to aspirin or NSAIDs (for NSAID gels)
- People with severe liver or kidney failure (for NSAID gels - though risk is low)
- Anyone who can’t tolerate the initial burning of capsaicin
Real People, Real Results
Patient feedback tells a mixed story. On Reddit, one user wrote: “The 8% capsaicin patch cut my PHN pain from 8/10 to 3/10 - but the first 10 minutes felt like my skin was boiling.” Another said: “Voltaren gel takes 45 minutes to work, but then I get 6 hours of relief without my stomach screaming.” A 2019 survey of 250 chronic pain patients found 68% saw moderate to significant improvement with topical NSAIDs. But 45% said the relief was inconsistent - often because they didn’t apply enough, didn’t massage it in, or applied it to dry, flaky skin. Skin reactions are common. About 10-30% of users get redness, itching, or peeling. Lidocaine patches cause mild redness in 5-15%. Capsaicin creams cause burning in nearly half. But most side effects fade with time.How to Use Them Right
You can’t just slap it on and expect results. Here’s how to get the most out of each: Lidocaine patches:- Apply only to intact skin
- Use no more than three patches at a time
- Leave on for exactly 12 hours, then remove for 12 hours
- Don’t use with heating pads - risk of burns
- Wash hands immediately after applying - never touch eyes or nose
- Apply 3-4 times daily
- Expect burning for 1-2 weeks before pain improves
- Use gloves or a applicator to avoid burning your fingers
- Apply a 2-4 inch ribbon (about the size of a quarter) 4 times a day
- Wait 30 minutes before washing or showering
- Massage gently - don’t rub hard
- Don’t cover with bandages unless directed
- Use only on areas you can reach - no need to apply to hips or lower back
What’s Coming Next
Science is moving fast. New nanoemulsion gels - like the one tested in a 2023 clinical trial - deliver 2.3 times more diclofenac into the tissue without raising blood levels. That could mean better pain relief with even fewer side effects. Researchers are also exploring resiniferatoxin (RTX), a compound 1,000 times stronger than capsaicin. It’s being studied for severe osteoarthritis, but it doesn’t absorb well through skin yet. Once that’s solved, it could offer months of relief from a single application. The future of pain relief isn’t just about stronger drugs - it’s about smarter delivery. Targeting specific nerve receptors. Avoiding the bloodstream entirely. Reducing pills. That’s why top pain societies now recommend topical analgesics as first-line treatment for localized pain.Frequently Asked Questions
Can I use lidocaine patches and NSAID gel together?
Yes, you can. They work in different ways - lidocaine blocks nerve signals, while NSAIDs reduce inflammation. Many people use both, especially for complex pain like arthritis with nerve involvement. Just apply them at different times and avoid overlapping application areas to reduce skin irritation.
How long does it take for capsaicin cream to work?
It takes time. With OTC capsaicin cream (0.025%-0.1%), you need to apply it 3-4 times a day for 2 to 6 weeks before you feel consistent relief. The initial burning may last 1-2 weeks, but that’s your nerves adapting. Don’t quit too soon - most people who stick with it report good results.
Are topical NSAIDs safer than oral ones?
Much safer - especially for your stomach and kidneys. Studies show gastrointestinal side effects are 50 times lower with topical NSAIDs. Cardiovascular risk is also lower, though the FDA still requires a warning label. For most people, especially older adults, topical NSAIDs are the safer choice for joint pain.
Can I use topical analgesics if I’m on blood thinners?
Yes, generally. Because topical analgesics don’t enter your bloodstream in significant amounts, they rarely interfere with blood thinners like warfarin or apixaban. Lidocaine patches and capsaicin are especially low-risk. NSAID gels carry a small theoretical risk, but studies show no increased bleeding compared to placebo. Still, check with your doctor if you’re unsure.
Why doesn’t my Voltaren gel work on my hip pain?
Because your hip is too deep. Topical gels only penetrate 5-10 mm into the skin - enough for knees, elbows, or wrists, but not for joints under layers of muscle and fat. For hip pain, you’ll need oral meds, injections, or physical therapy. Topical gels won’t reach the source.
Paul Dixon
December 11, 2025 AT 11:35Just tried the Voltaren gel for my knee after reading this. Took me a week to believe it worked, but now I use it daily. No more stomach issues from the pills. Just wish I’d known sooner.
Jimmy Kärnfeldt
December 12, 2025 AT 11:34It’s wild how much we’ve underestimated topical treatments. We’re so used to swallowing pills like they’re candy, but the body’s got this whole other pathway right under our skin. Capsaicin sounds brutal, but if it shuts down nerve pain for months? I’d take the burn. Science is quietly revolutionizing pain management, and most people still think ibuprofen is the only option.
matthew dendle
December 13, 2025 AT 20:38lol i used the capsaicin cream and thought i was gonna die. 10/10 would burn again. my knee feels like a ghost touched it now. no more pills. no more doctor visits. just me and my chili pepper vengeance
Taylor Dressler
December 14, 2025 AT 21:27One thing I wish more people understood: topical NSAIDs only work if you use the full dose. I see so many folks dabbing a pea-sized amount on their knee and wondering why it doesn’t work. It’s not magic-it’s pharmacokinetics. A 2-4 inch ribbon isn’t a suggestion; it’s the minimum. And don’t wash your hands right after-wait the full 30 minutes. You’d be amazed how many people skip that and then blame the product.
Also, lidocaine patches? Perfect for neuropathic pain, but they’re not for muscle soreness. That’s a common misconception. They block nerves, not inflammation. Use them for the right thing, and they’re life-changing.
And for anyone scared of capsaicin: start with the OTC cream. The burning fades. The relief doesn’t. I’ve had patients quit after three days. I tell them: if you can tolerate the burn for a week, you’ll thank yourself for the next six months.
Topical analgesics aren’t second-tier. They’re precision tools. Like using a scalpel instead of a sledgehammer. We need to stop treating them like backup options and start using them like first-line therapy.
And yes, you can use lidocaine and diclofenac together-just don’t overlap the patches and gels on the same spot. Skin irritation is real, but avoidable.
Also, if your hip hurts? Don’t waste money on gel. It won’t reach. Go see a PT. Or consider an injection. Topicals are amazing, but they’re not universal.
Finally, if you’re on blood thinners: yes, it’s safe. The data is solid. But always check with your pharmacist. They know the nuances better than most doctors these days.
Courtney Blake
December 16, 2025 AT 20:13Ugh. Another ‘topical is better’ post. Let’s be real-these things barely work. I tried everything. Capsaicin burned for weeks and did nothing. Voltaren? Felt like I rubbed lotion on. My grandma used these and still ended up on opioids. This is just placebo marketing dressed up as science. 🙄
Eddie Bennett
December 18, 2025 AT 00:52I get where Courtney’s coming from-I tried capsaicin too and almost threw the tube out. But then I stuck with it. Week 3, something clicked. The pain didn’t vanish, but it stopped keeping me up. I think a lot of people give up before the real benefit kicks in. It’s not instant. It’s like training a muscle. Your nerves have to learn to be quiet.
Also, I used to think topical NSAIDs were for wimps. Turns out, they’re for smart people. My dad’s on three meds for his heart. He can’t take oral NSAIDs. This? This kept him off pills for two years. No stomach bleeding. No ER visits. Just a little tube and some patience.
Ariel Nichole
December 19, 2025 AT 15:18Just wanted to say thanks for the detailed breakdown. I’ve been using the lidocaine patch for my sciatica and it’s been the only thing that helps. I used to think it was just a ‘cool’ thing for old people, but now I get it. It’s not about age-it’s about smart delivery. Keep sharing this kind of stuff.
Sylvia Frenzel
December 19, 2025 AT 19:31Why do people keep pretending these are miracle cures? You still need to move, stretch, strengthen. Topicals are a bandaid. Literally. They don’t fix the problem, they just mute the alarm. And don’t even get me started on the cost of that 8% patch. $600 for one use? That’s robbery. This whole post feels like a pharma ad with footnotes.