Topical Arthritis Pain Relief
That Doesn't Wreck Your Stomach
Medically Reviewed By: Jennifer Brown, MD · Board-Certified Family Medicine
Yes. The ACR strongly recommends topical NSAIDs for knee osteoarthritis and conditionally recommends them for hand osteoarthritis, and says to consider them before oral NSAIDs because they carry the least systemic exposure. In the 2016 Cochrane review of 39 osteoarthritis trials, topical diclofenac reached a number needed to treat of 9.8 for clinical success over 6 to 12 weeks.
Osteoarthritis is the most common form of arthritis, affecting over 32.5 million Americans (CDC). It occurs when the protective cartilage cushioning your joints breaks down, causing bone-on-bone friction, inflammation, and progressive pain, most commonly in the knees, hips, hands, and spine. Most people manage it with pills that damage their gut over time. There's a better way: topical arthritis treatment that delivers medication directly where the pain is, not through your entire body first.
32.5M
Americans with OA (CDC)
10,631
Chronic Cochrane participants
5-17x
Lower exposure, diclofenac gel vs oral
$110/mo · prescribed online · consultation included
Last updated May 8, 2026
Arthritis Pain Relief: Key Takeaways
- The ACR 2019 guideline strongly recommends topical NSAIDs for knee osteoarthritis and conditionally recommends them for hand osteoarthritis, to be considered before oral NSAIDs.
- The 2016 Cochrane review (Derry et al., 39 trials, 10,631 participants) put topical diclofenac at a number needed to treat of 9.8 for clinical success over 6 to 12 weeks. Separately, topical diclofenac 1% gel produced 5-17x lower systemic exposure than oral diclofenac in healthy volunteers.
- Hands and knees respond especially well to topical delivery because the target tissue sits close to the skin surface.
- A 2019 meta-analysis of topical NSAIDs in osteoarthritis found no significant difference in gastrointestinal adverse events versus placebo (OR 0.96, 95% CI 0.73 to 1.27). Total adverse events were slightly higher, mostly skin reactions. Lower systemic exposure than an oral NSAID means lower risk, not no risk.
From $110/month. Prescribed online, consultation included.
Osteoarthritis (OA) is the most common form of arthritis, caused by the gradual breakdown of cartilage in joints. It affects over 32.5 million adults in the US, most commonly in the knees, hands, and hips.
Quick Facts
- ACR 2019: topical NSAIDs strongly recommended for knee OA, conditionally for hand OA
- 32.5 million US adults affected, the most common joint disease
- Cochrane 2016: few head-to-head trials against oral NSAIDs, rated low quality, showing similar efficacy
- Kienzler 2010: topical diclofenac 1% gel produced 5-17x lower systemic exposure than oral diclofenac in healthy volunteers
- Hands and knees respond especially well: target tissue is close to the skin surface
- Risk increases with age, prior joint injury, and obesity
Understanding Arthritis: What's Happening in Your Joints
Osteoarthritis isn't just "wear and tear." It's an active inflammatory process. The cartilage that cushions your joints breaks down, bone rubs against bone, and your body's inflammatory response makes everything worse: stiffness, swelling, pain that builds through the day.
It hits knees, hips, hands, and spine the hardest. Some days you're fine. Other days, opening a jar feels impossible. The unpredictability is part of what makes it so frustrating. For women in midlife, estrogen decline accelerates this process. See menopause-related joint pain relief for how hormone shifts drive the same inflammatory pattern.
#1
Most common form of arthritis worldwide. Affects 1 in 7 adults over 25 (CDC). Risk increases with age, joint injury, obesity, and repetitive stress.
Most people reach for oral NSAIDs: ibuprofen, naproxen, celecoxib. They work, and the same ACR guideline still strongly recommends them. But they treat your entire body to address pain in one joint, and after years of daily use the side effects add up. That is why guidelines now say to consider a topical NSAID first. That recommendation is for the drug class, not for any named product: the trial evidence behind it comes from diclofenac and ketoprofen, and no trial of a compounded topical ketorolac in osteoarthritis has been published. A licensed provider can advise where each option fits, including Ketro's compounded topical ketorolac.
"I can do next to nothing one day and feel like I've been hit by a truck the next. Twenty-five years of NSAIDs and now my stomach is wrecked. Nobody warned me."
- Arthritis patient, online community
What People Try for Arthritis. And Why It Falls Short
Most arthritis treatments either work but damage your body over time, or they're safe but barely effective. That's the tradeoff people have accepted for decades.
Oral NSAIDs (Ibuprofen, Naproxen)
Effective for pain, but systemic. Your kidneys, liver, heart, and GI tract all absorb the drug when you only need it in one joint. Long-term use linked to stomach ulcers, bleeding, and cardiovascular events.
Effective but risky long-term
Ice & Heat Packs
Temporary numbness, not treatment. Doesn't address the underlying inflammation. Relief lasts 20-30 minutes, then you're back where you started.
Temporary, no anti-inflammatory effect
Glucosamine & Chondroitin
Heavily marketed, but the evidence is mixed at best. Multiple large-scale trials (GAIT, LEGS) found no significant benefit over placebo for most patients.
Weak evidence, expensive
Cortisone Injections
Fast-acting but limited. You can only get them every 3-4 months. Repeated injections may actually accelerate cartilage loss. And the needle isn't exactly pleasant.
Limited frequency, may worsen cartilage
OTC Topicals (Voltaren, Bengay)
Two different things in one aisle. Voltaren is diclofenac sodium 1%, a topical NSAID whose label is written for arthritis pain, and it is the over-the-counter option guidelines point to. Bengay and similar rubs are menthol and salicylate counterirritants that act on sensation rather than inflammation. The Voltaren label limits use to six joints, two body areas at a time, and 21 days without a doctor.
A real option, on a narrow label
Physical Therapy Alone
Essential for long-term joint health, but doesn't replace anti-inflammatory treatment during flares. Most people need both. PT for function, medication for inflammation.
Necessary but not sufficient alone
"I've been on ibuprofen for years. My doctor finally told me my kidney function is declining. But what am I supposed to do, just live with the pain?"
- Arthritis patient, online community
Anti-Inflammatory Cream for Arthritis: What Is Actually in Each One
One class of arthritis cream acts on inflammation: topical NSAIDs. Diclofenac 1% gel is the only OTC topical NSAID available in the US. Capsaicin, lidocaine, menthol, camphor and methyl salicylate work differently. The ACR strongly recommends topical NSAIDs for knee osteoarthritis and conditionally recommends them for hand osteoarthritis. Topical capsaicin is also conditionally recommended for knee OA.
| Active ingredient | Sold as | Mechanism | 2019 ACR guideline |
|---|---|---|---|
| Diclofenac sodium 1% (topical NSAID) | Voltaren sells it, and so do store brands and other labels, including Aspercreme Arthritis Pain (the same molecule at the same strength). OTC since 2020. Also dispensed as a prescription gel. | Inhibits COX enzymes | Topical NSAIDs strongly recommended for knee OA, conditionally recommended for hand OA |
| Capsaicin | Zostrix and store brands | Acts on sensory nerve endings | Conditionally recommended for knee OA. Conditionally recommended against for hand OA, partly because of the risk of getting it in the eye. |
| Lidocaine | Aspercreme with Lidocaine, OTC patches and creams | Blocks sodium channels in peripheral nerves | "Insufficient data exists to make recommendations about the use of topical lidocaine preparations in OA" |
| Menthol, camphor, methyl salicylate | Biofreeze, Icy Hot, Bengay, Tiger Balm | Creates a competing cold or warm sensation | Not addressed in this guideline |
Guideline column reflects a full-text reading of the 2019 American College of Rheumatology and Arthritis Foundation guideline for hand, hip and knee OA (Kolasinski et al., PubMed 31908149). That document makes recommendations on topical NSAIDs, topical capsaicin and topical lidocaine. It does not cover menthol or salicylate rubs. Absence from one guideline is not the same as evidence that something does nothing.
One detail gets missed in almost every roundup: over-the-counter diclofenac gel and prescription diclofenac gel are both 1%. The prescription version is not a higher concentration. What the prescription label adds is a broader description of which joints it covers, "osteoarthritis of joints amenable to topical treatment, such as the knees and those of the hands," dosing limits set per joint rather than per body area, and a prescriber deciding how long you stay on it. Prescription diclofenac also comes as a topical solution at 1.5% and 2%, both indicated for osteoarthritis of the knee.
Arthritis Cream by Joint: Knee, Hand, Hip and Spine
Topical NSAID labels name the joints they cover, and the lists are short. The OTC diclofenac gel label covers arthritis pain in the hand, wrist, elbow, foot, ankle and knee, and says not to use the product on the back, hip or shoulder. The 2019 ACR guideline recommends topical NSAIDs for knee and hand OA, and did not examine hip OA at all.
KNEE
Strongest Guideline Support
The ACR strongly recommends topical NSAIDs for knee OA. OARSI's 2019 guideline reached the same conclusion at Level 1A. The knee appears on both the OTC and the prescription diclofenac labels, and prescription diclofenac topical solution 2% is indicated for the knee specifically.
HAND
Hand, Wrist and Elbow
The ACR conditionally recommends topical NSAIDs for hand OA. The guideline attributes the weaker grade to practical considerations such as frequent hand washing and to a lack of direct evidence of efficacy in the hand. The OTC diclofenac label covers hand, wrist and elbow at 2 grams per area.
HIP
Hip, Spine and Shoulder
The ACR voting panel did not examine topical NSAIDs in hip OA, so the guideline makes no recommendation there. The prescription diclofenac gel label states the product has not been evaluated on the spine, hip or shoulder, and the OTC label says not to use it on those areas.
That third card is the honest edge of this category. Hip and spine osteoarthritis are common, and they sit outside what topical NSAIDs are labeled or recommended for. If that is where your pain is, a licensed provider can advise where each option fits.
What the Labels Say About Using It
- How often. OTC diclofenac gel 1%: four times a day, 2 grams per upper body area or 4 grams per lower body area, no more than 2 body areas at once.
- How long before it does anything. The OTC Drug Facts label says the product "may take up to 7 days to work for arthritis pain."
- How long you can use it without a doctor. The OTC label caps use at 21 days unless a doctor directs otherwise, and tells you to stop and see a doctor if pain gets worse or lasts more than 21 days.
- Prescription dosing. Diclofenac gel 1% Rx: four times a day, up to 8 grams a day on any single upper-extremity joint, 16 grams on any single lower-extremity joint, 32 grams a day in total. Diclofenac topical solution 2%: two pump actuations on each painful knee, twice a day.
- What the trials measured. The osteoarthritis trials behind the 2016 Cochrane review ran 6 to 12 weeks, so that is the window the evidence speaks to.
- Compounded gels. A compounded prescription such as Ketro RX Pain Gel is dosed by the prescriber, so follow the instructions that come with yours rather than an OTC label.
What Rheumatologists Recommend for Arthritis Pain
This is not alternative medicine. The ACR strongly recommends topical NSAIDs for knee osteoarthritis and conditionally recommends them for hand osteoarthritis, and says they should be considered prior to oral NSAIDs. Topical capsaicin is also conditionally recommended for knee OA. OARSI's 2019 guideline reached the same conclusion for topical NSAIDs in the knee.
10,631
Chronic Cochrane Participants
The 2016 Cochrane review (Derry et al., 39 trials, all in osteoarthritis) found topical diclofenac and ketoprofen provide good levels of pain relief beyond carrier for a minority of people, over 6 to 12 weeks.
5-17x
Lower Systemic Exposure
In healthy volunteers, topical diclofenac 1% gel produced 5-17x lower systemic exposure than oral diclofenac. That is a diclofenac finding, not a figure for topicals in general.
NO DIFF
GI Events vs Placebo
A 2019 meta-analysis found no significant difference in GI adverse events between topical NSAIDs and placebo (OR 0.96). Total adverse events ran slightly higher, mostly skin reactions.
Topical NSAID vs. Oral: How Arthritis Treatment Delivery Matters
Topical NSAIDs are applied to the skin over the painful area rather than swallowed. In healthy volunteers, topical diclofenac 1% gel produced 5-17x lower systemic exposure than oral diclofenac (Kienzler 2010). Separately, the 2016 Cochrane review (Derry et al.) of 39 osteoarthritis trials with 10,631 participants put topical diclofenac at a number needed to treat of 9.8 for clinical success over 6 to 12 weeks, and topical ketoprofen at 6.9.
Topical Delivery
Applied to the skin over the painful area rather than swallowed. Lower systemic exposure than the same drug taken by mouth.
- Applied where it hurts, not swallowed
- Diclofenac gel 1%: 5-17x lower systemic exposure than oral diclofenac
- No significant difference in GI adverse events vs placebo (Honvo 2019)
- Lower systemic exposure than oral, so lower systemic risk. Lower, not zero.
- Can be used alongside other treatments
Oral Systemic
Pill dissolves in the stomach, enters the bloodstream and circulates through the whole body, not only the painful joint.
- Treats entire body for one joint's problem
- Full systemic drug exposure
- GI bleeding risk increases with duration
- Kidney function declines over years
- Cardiovascular risk with long-term use
Prescription Arthritis Cream + Daily Magnesium
Prescription-strength relief for flares. A soothing daily magnesium cream for general comfort. Topical delivery puts medication where your joints need it.
For Flares & Severe Pain
RX Pain Gel
Prescription compounded topical ketorolac, prepared per prescription by a US pharmacy and applied where it hurts. Originally developed by the same compounding team that works with professional sports organizations, including the Boston Red Sox. Topical NSAIDs as a class produce lower systemic exposure than the same drug taken by mouth, studied most directly with diclofenac (Kienzler 2010). Equivalent published data for compounded topical ketorolac do not exist.
- Prescription-strength ketorolac (topical NSAID)
- Topical NSAID class: lower systemic exposure than oral
- Compounded per order by US pharmacy
- Online consultation included
For Daily Maintenance
CALM Magnesium Cream
Skincare-formulated topical magnesium. Magnesium plays a role in muscle function generally. Some users find CALM soothing as part of a daily comfort routine, though evidence for topical magnesium as an arthritis treatment is limited.
- Premium transdermal magnesium delivery
- Soothing daily comfort routine
- Fast-absorbing, non-greasy formula
- Formulated like skincare, not drugstore
- No prescription needed
"Recommended by my chiropractor for my bad shoulder knots. Life changing!!!"- Amy G., Verified CALM: Magnesium Cream review
$110/mo · prescribed online · consultation included
Topical NSAIDs for Osteoarthritis: What the Research Shows
Real studies, real data. Not marketing claims: peer-reviewed evidence supporting topical NSAID for arthritis as the modern standard of care.
ACR 2019 Guideline. Topical Before Oral
The 2019 American College of Rheumatology and Arthritis Foundation guideline strongly recommends topical NSAIDs for knee osteoarthritis and conditionally recommends them for hand osteoarthritis. It states that topical NSAIDs should be considered prior to use of oral NSAIDs, in keeping with the principle that medications with the least systemic exposure are preferable. The panel did not examine topical NSAIDs in hip OA.
Cochrane Review. Topical NSAIDs for Chronic Musculoskeletal Pain (N=10,631)
The 2016 Cochrane systematic review (Derry et al., 39 trials, 10,631 participants) looked at topical NSAIDs for chronic musculoskeletal pain. Every included study was in osteoarthritis. Over 6 to 12 weeks, topical diclofenac reached a number needed to treat of 9.8 for clinical success and topical ketoprofen 6.9, both moderate quality evidence, and both against carrier response rates near 50%. The authors' conclusion is that these two provide good levels of pain relief beyond carrier for a minority of people.
Safety. Lower Systemic Exposure, Not Zero
A 2019 meta-analysis in Drugs and Aging found no significant difference in gastrointestinal adverse events between topical NSAIDs and placebo (OR 0.96, 95% CI 0.73 to 1.27), with slightly more total adverse events and withdrawals, mostly skin reactions. Separately, a pharmacokinetic study in healthy volunteers found topical diclofenac 1% gel produced 5-17x lower systemic exposure than oral diclofenac (Kienzler 2010). Both prescription diclofenac labels we checked carry the NSAID class boxed warning for serious cardiovascular and gastrointestinal events.
Kienzler et al., J Clin Pharmacol | Drugs & Aging 2019
Ketro vs. Voltaren and Oral NSAIDs
| Feature | Ketro RX | Oral NSAIDs | OTC Topicals |
|---|---|---|---|
| Potency | Prescription-strength | Prescription available | OTC only |
| Route | Applied to the skin | Swallowed, systemic | Applied to the skin |
| GI Side Effects | Topical NSAID class: no significant difference vs placebo | Significant with long-term use | Minimal |
| Kidney Impact | Minimal systemic exposure | Risk increases over time | Minimal |
| Efficacy (OA) | No product-specific OA trial published. Topical NSAID class evidence only. | Strongly recommended for knee, hip and hand OA (ACR 2019) | Topical diclofenac NNT 9.8 over 6 to 12 weeks (Cochrane 2016) |
| Origin | Originally developed by the same compounding team that works with professional sports organizations, including the Boston Red Sox | Generic pharmaceutical | Mass-market |
| Customization | Compounded per patient | Standard dosing | Standard dosing |
When to See a Doctor for Arthritis Pain
Most arthritis pain is manageable at home with topical NSAIDs, daily movement, and lifestyle adjustments. But certain symptoms point to inflammatory arthritis (rheumatoid, psoriatic, gout), joint infection, or a different underlying condition. These need urgent evaluation, not a topical cream.
Seek Medical Care If You Experience:
- Sudden severe joint pain with fever, redness, or warmth. Possible septic arthritis or gout flare. Septic arthritis is a medical emergency.
- Morning stiffness lasting more than an hour. A hallmark of inflammatory arthritis (rheumatoid, psoriatic, ankylosing spondylitis). Different treatment than osteoarthritis.
- Multiple joints swelling symmetrically. Both wrists, both knees, both hands at once. Suggests rheumatoid arthritis or another autoimmune condition.
- Joint pain after a fall or injury that won't bear weight. Rule out fracture or ligament tear before assuming arthritis.
- Unexplained weight loss, fatigue, or rash with joint pain. Systemic symptoms point to autoimmune or inflammatory disease, not OA.
- Joint pain that wakes you up at night or worsens at rest. Mechanical OA pain typically improves with rest. Pain at rest can indicate inflammatory arthritis.
- You are pregnant or breastfeeding. Talk to your obstetrician before starting any topical or oral NSAID. NSAIDs are generally avoided in the third trimester.
Topical NSAIDs like Ketro RX Pain Gel are appropriate for mechanical osteoarthritis pain. They don't replace evaluation when red-flag symptoms appear. If your arthritis pain has changed in pattern, location, or intensity, a primary care doctor or rheumatologist can confirm the diagnosis and adjust treatment.
Arthritis Pain Relief FAQ
Topical Relief for Other Conditions
TMJ / Jaw Pain
Topical delivery is especially effective for jaw pain: the masseter muscle sits right under the skin. Minimal systemic exposure from treating one small area.
Learn More →Fibromyalgia
A small Mayo Clinic pilot (N=40, spray) found preliminary symptom improvement, though evidence remains limited. Topical NSAIDs target flare hot spots without adding to the medication carousel.
Learn More →Back Pain
A Phase 4 trial at Montefiore compared topical vs. oral NSAIDs for back pain. Topical delivery avoids GI issues from the drugs most back pain patients rely on daily.
Learn More →Targeted treatment for arthritis pain. Medication that goes where it hurts, not through your entire body first.
This content is for informational purposes only and does not constitute medical advice. Consult a healthcare provider before starting any new treatment. Individual results may vary. Ketro RX Pain Gel requires a prescription. Clinical data referenced from published peer-reviewed studies.
Ketro Arthritis Relief
Prescription-strength topical + daily magnesium