Topical options Figure 191a Capsaicin

The knowledge that repeated application of capsaicin, an extract from the chili pepper, can cause pain reduction is old and well known. Capsaicin may achieve its analgesic effect by virtue of its effects on reversibly depleting substance P and by reducing the density of epidermal nerve fibers. This effect may take weeks to become maximal and usually the unpleasant discomfort of application reduces as time progresses. However, compliance is reduced because many find the burning discomfort of application intolerable. Even when it has reduced with time, should the application be accidentally applied outside the normal zone of application, a recurrence of the worst excesses of application pain may recur. Intuitively one would expect it to work best where the distance from skin to joint is small. The discomfort of application can be reduced by adding glyceryl trinitrate to the capsaicin, as described in an earlier chapter.

Monoarticular options Topical/transdermal

Glyceryl trinitrate patch

Capsaicin cream 0.025%

Lidocaine patch

Lidocaine patch

Doxepin cream 5%

Non-steroidal anti-inflammatory

Buprenorphine patch, fentanyl TDDS (not necessarily over painful joint)

Doxepin cream 5%

Non-steroidal anti-inflammatory

Buprenorphine patch, fentanyl TDDS (not necessarily over painful joint)

Corticosteroid

Corticosteroid

5HT3 antagonist Hyaluronic acid (osteoarthritis)

Figure 19.1 Suggested treatment algorithms for monoarticular pain. (a) Topical/ transdermal options. (b) Intra-articular options.

Non-steroidal Acetamm°phen anti-inflammatory

Non-steroidal Acetamm°phen anti-inflammatory

Figure 19.1 (Continued). (c) Oral options. (d) Parenteral options.

Figure 19.1 (Continued). (c) Oral options. (d) Parenteral options.

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