Topical NSAIDs: good relief for acute musculoskeletal pain

A brief look at the evidence on topical non-steroidal anti-inflammatory drugs (NSAIDs), which are applied to the skin for painful conditions like sprains, strains and muscle soreness.

Page last updated: 27 July 2022.

Non-steroidal anti-inflammatory drugs (NSAIDs) are routinely prescribed for mild to moderate pain and are the most commonly prescribed painkilling drugs worldwide. Taken by mouth or injected into a vein, the high concentrations of the drug throughout the body, necessary in order to work at the site of pain and inflammation, can cause unpleasant or even serious side effects. Applied to the skin, so in a topical preparation such as a gel, cream or plaster, they can act where needed to relieve pain without affecting the rest of the body. For superficial painful conditions like sprains, strains and muscle soreness (and where the skin is unbroken) topical NSAIDs offer this clear advantage over taking tablets, as long as they work.

How good are topical NSAIDs?

A Cochrane Review Topical NSAIDs for acute musculoskeletal pain in adults (published June 2015) has been updated with new research confirming that topical NSAIDs are an effective and safe means of relieving acute musculoskeletal pain in adults. The new evidence also tells us much more than we knew before about which ones work best.

The evidence comes from 61 randomized controlled trials (RCTs) with 8386 people. Several different topical NSAIDs were compared, mostly with placebo in the same carrier – so gel with a drug compared to the gel without a drug, for example. Both would be rubbed into the skin so we know that any effect is not just from rubbing. The reviewers were interested in whether people’s pain was reduced by at least half around seven days after starting treatment.

Here’s what they found:

  •  Topical NSAIDs gave much better pain relief than placebo
  • Gel formulations of diclofenac, ibuprofen and ketoprofen, and some diclofenac patches, were the most effective. For diclofenac and ketoprofen gels, 7 or 8 people out of 10 with a painful strain, sprain, or muscle pull had much reduced pain after seven days, compared with only 2 or 3 out of 10 with placebo
  • Other NSAIDs and formulations were better than placebo, but not by as much
  •  About 1 in 20 had a mild and short-lived side effect like redness at the application site and this was the same for topical NSAID or placebo. Side effects like stomach upset were uncommon and there was no difference between topical NSAID and placebo. There were no serious side effects

How reliable is this evidence?

  • The evidence is high quality
  • It wasn’t possible to compare topical NSAIDs with each other or with the same oral drug
  • Recent research has provided us with much more information, especially about topical diclofenac
  • There is a lot of unpublished data which could influence results in future updates of the review

The bottom line

The reviewers conclude that “topical NSAIDs provided good levels of pain relief in acute conditions such as sprains, strains and overuse injuries, probably similar to that provided by oral NSAIDs.” Sheena Derry, a Senior Research Officer at the University of Oxford and lead author of the review, said “this Cochrane Review offers important news to patients and clinicians; out of the topical NSAID options, gel formulations work best and they are a safe alternative to oral drugs.”

Topical painkillers for chronic pain

Another reviewby Sheena Derry and colleagues, Topical NSAIDs for chronic musculoskeletal pain in adults (published April 2016) found that topical diclofenac and topical ketoprofen probably provide good levels of pain relief in osteoarthritis, but only for about 10% more people than get this result with topical placebo. There is no evidence for other chronic painful conditions.

As for those creams that make your skin red and hot when you rub them on, because they increase the blood flow, Derry and team’s review on these: Salicylate‐containing rubefacients for acute and chronic musculoskeletal pain in adults (published November 2014) found only poor quality evidence that leaves us uncertain about their effects.

Links:

Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD007402. DOI: 10.1002/14651858.CD007402.pub3.

Derry S, Conaghan P, Da Silva JAP, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD007400. DOI: 10.1002/14651858.CD007400.pub3. Accessed 27 July 2022.

Derry S, Matthews PRL, Wiffen PJ, Moore RA. Salicylate-containing rubefacients for acute and chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD007403. DOI: 10.1002/14651858.CD007403.pub3.



Topical NSAIDs: good relief for acute musculoskeletal pain by Sarah Chapman

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

1 Comments on this post

  1. It’s good to see some high quality evidence on the use of topical NSAIDs, I think for years patients have found them useful, but there has often been a scepticism expressed by medics due to the poor data at the time. Hopefully that is now resolved.

    My personal favorite had always been ketoprofen.

    Roger / Reply

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