The use of topical pain medications for the treatment of chronic pain is widely adopted due to the lack of systemic effects of many of these preparations.  Many painful conditions can be treated in this manner.  Topical formulations of non-steroidal anti-inflammatory medications (NSAIDS) are often used.  Voltaren gel and Pennsaid are a topical formulation of diclofenac, a NSAID. Capsaicin is a topically applied, over-the-counter pain medication that initially causes burning due to the release of substance P, followed by pain relief in the area.  Local anesthetics such as lidocaine can also be applied topically.  These can come as patches, liquids or gels.  Care must be taken as these agents can also be absorbed systemically and reach toxic levels.  Always follow the manufacturer’s guidelines to avoid problems.  Some other medications such as anticonvulsants, anti-depressants and NMDA antagonists such as ketamine have also been used.  Compounding pharmacies can produce a variety of these medications in different formulations depending on the intended target.  Many types of painful conditions can be treated such as musculoskeletal pain, bursitis, osteoarthritis, complex regional pain syndrome, diabetic neuropathy and other types of neuropathy.  The use of electricity (iontophoresis) and ultrasound (phonophoresis) can enhance the effectiveness of these preparations.  Medications applied topically can often be used safely when compared to the same medications when given orally.  Many of these medications’ side effects can be avoided when they are given topically.  Of course, there are always complications and side effects that can occur.  The use of topical medications should always be guided by discussion with your pain management physician.