FormalPara Key Summary Points
The most commonly used topical anesthetic that pain physicians prescribe is diclofenac gel, but it may not be that effective.
This is a response article where we agree with the usage of capsaicin gel alongside diclofenac for maximal patient satisfaction.
Topical anesthetics are safer options for patients with numerous comorbidities, which is common in the chronic pain population.

Dear Editor,

We read the study by Predel et al. “Efficacy and Safety of Diclofenac + Capsaicin Gel in Patients with Acute Back/Neck Pain: A Multicenter Randomized Controlled Study” with great interest [1]. We agree with the study’s emphasis on the importance of topical analgesics. In the treatment of patients with chronic pain, utilizing a truly multimodal analgesic regimen is of the utmost importance, of which topical analgesics represent a vital spoke on the treatment wheel. In addition, these patients oftentimes have numerous comorbidities that limit the amount of oral analgesics physicians can prescribe to alleviate their patients’ symptomatology [2]. Or, they have overused anti-inflammatory medications to treat their chronic pain to the point that their liver and kidney function has been negatively impacted. Topical analgesics have been proven to be effective at treating pain, but more importantly are safer than oral analgesics owing to less systemic absorption [3, 4].

With the tremendous reliance on opioid medications throughout the patient population, there has been a push to move to different modalities for treating chronic pain. Topical analgesics offer a safer option that patients of all ages and comorbidities can utilize. Typically, the non-steroidal anti-inflammatory drugs (NSAIDs) like diclofenac are the first-line therapy for many ailments [5]. There has been some controversy within the pain community of the efficacy of diclofenac. Although it has been shown to be a potent anti-inflammatory, its ability to control a patient’s pain is questionable.

Capsaicin gel is a proven option for patients suffering from arthritis, chronic pain, gastrointestinal disorders, and cancer. It works mainly through interaction with the transient receptor potential cation channel subfamily V member 1 (TRPV1) or capsaicin receptor [6]. The article echoes the immense potential capsaicin gel has as a topical anti-inflammatory promoting substantial pain relief.

The addition of diclofenac with capsaicin potentiated the analgesic effect whereas diclofenac alone showed no benefit compared to the placebo group. This study brings positive findings to light that pain physicians should consider utilizing capsaicin gel along with diclofenac gel as a first-line therapy for their patients with chronic pain rather than simply diclofenac alone. This study exemplifies this point and debunks some of the question about how useful diclofenac therapy is alone. In our practice it is commonplace to escalate analgesic therapy quickly after prescribing diclofenac as a result of insufficient pain relief. We now might have some substantial evidence as to why. We would like to thank the study’s authors for bringing to light the importance of continued utilization of topical analgesics and potentially improved way of doing so.