Over-the-counter options include lidocaine cream or patches (max 4% strength), applied 12 hours on and 12 hours off, for localized pain relief. Capsaicin cream (0.075%) may also help by desensitizing nerves but can cause initial discomfort; avoid in diabetes. For moderate-to-severe cases, prescription medications like gabapentin, pregabalin, duloxetine, or amitriptyline may be necessary, along with professional evaluation for refractory cases.
January 14, 2025

Peripheral Neuropathy: Best Over-the-Counter Pain Relief

Evidence-Based Over-The-Counter Guide

William Shen

William Shen

Co-founder & CPO

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Peripheral neuropathy involves nerve damage, leading to symptoms such as numbness, tingling, and pain, commonly associated with diabetes, chronic alcohol use, or other systemic conditions. 

First-line therapy tend to be prescription medications such as gabapentin. However, the side effect profile of TCAs, SNRIs, and gabapentanoids requires extremely cautious dosing in many patients, especially the elderly, with some patients having side effects with the lowest available doses. Hence, some guidelines include topic over-the-counter options in their first-line recommendations.

First-line recommendations:

  • Lifestyle modifications: Optimize glucose control in diabetic patients to prevent further nerve damage. Avoid alcohol and ensure adequate intake of vitamins like B12.

  • Lidocaine: 5% topical lidocaine (max 4% without a prescription per FDA regulations) works by decreasing ectopic firing of peripheral nerves. Available as cream such as Aspercreme Lidocaine Pain Relief Liquid with Roll-On (FDA M017) or patch such as Aspercreme Lidocaine Pain Relief Patch (FDA M017). Apply to site of pain 12 hours on, 12 hours off. Max of three patches at one time. Try for 3 weeks to assess effect. 

Second-line recommendations: 

  • Capsaicin cream: Apply High Potency Capsaicin 0.075% Cream to the affected area up to 4 times daily. Long-term exposure causes overstimulation, depletion of substance P, desensitization of the nerve. May be painful at first. If you a patch instead of cream, please ask your doctor first as they can cause significant discomfort. Do not use if you have diabetes. 

Prescription medications or professional intervention:

  • Gabapentin or Pregabalin: First-line for moderate-to-severe neuropathic pain.

  • Neurotransmitter uptake blockers: Duloxetine or amitriptyline

  • Physical therapy: Prescribed for improving mobility and reducing discomfort.

  • Nerve conduction studies or imaging: Performed by neurologists for refractory cases or unclear etiology.

Citation

Bates, D., Schultheis, B. C., Hanes, M. C., Jolly, S. M., Chakravarthy, K. V., Deer, T. R., ... & Hunter, C. W. (2019). A comprehensive algorithm for management of neuropathic pain. Pain Medicine, 20(Supplement_1), S2-S12.

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