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Q: My arthritis primarily affects my hands. Aleve helps but I don't want to rely on it every day. There are so many pain relieving skin creams. How do you choose?

A: You are wise to consider alternatives to oral naproxen (Aleve, Naprosyn), ibuprofen (Advil, Motrin) or other oral nonsteroidal anti-inflammatory drugs (NSAIDs). Long term use can lead to stomach and intestinal ulcers, internal bleeding, kidney damage and they potentially increase the risk of heart attack and stroke.

Topical analgesics are pain relievers that are applied to the skin instead of taken as pills. The most effective topical preparations do contain an NSAID. But topical NSAIDs pose less risk than the oral drugs because they result in lower NSAID blood levels.

Applying a topical NSAID concentrates the medicine near the pain site. So they can be very helpful for the more superficial joints like the hands, knees, ankles, feet, and elbows.

While only a small amount enters the bloodstream, topical NSAIDs may be off-limits to people at high risk for side effects. This would include people with a history of ulcers, internal bleeding and kidney disease.

Of the different topical NSAIDs, the prescription strength ones contain a higher concentration of active ingredient. Most studies have been done on diclofenac (Voltaren, generic versions) gel; and the research shows the gel can be as effective for arthritis in the hands and knees as the oral formulation of the drug.

There are many other types of topical pain relief products available over-the-counter. Typical ingredients include menthol, camphor, methyl salicylate, or capsaicin. Some combine a couple of these chemicals. While they are generally safe, many people find minimal if any symptom improvement.

Menthol and camphor are harmless substances that create a pleasing sensation that counteracts pain, but they don't influence the underlying cause or inflammation.

There's little rigorous research into methyl salicylate's effectiveness as a pain reliever. There definitely is some absorption of methyl salicylate and it's metabolized into salicylic acid, similar to aspirin. This should have some effect on pain and inflammation. People who have an aspirin allergy or take medications that interfere with blood clotting should check with their doctor before using a product containing a salicylate.

Capsaicin is the stuff that makes hot peppers so fiery. Rubbing them on the skin theoretically overloads the pain sensing circuits. While causing a burning sensation, little actually gets absorbed and the effectiveness of over-the-counter capsaicin is questionable.

(Howard LeWine, M.D., is an internist at Brigham and Women's Hospital in Boston and assistant professor at Harvard Medical School. For additional consumer health information, please visit www.health.harvard.edu.)

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