Selective TRPV1 agonist, topical analgesic for neuropathic pain
ATC code: N01BX04 (Capsaicin (high-concentration patch))
Brand names
Qutenza, Capzasin, Zostrix
Highly selective agonist of the TRPV1 receptor on cutaneous C and Aδ nociceptive fibres. After application it first depolarises fibres and causes burning; with prolonged exposure (8% patch for 60 minutes) it induces functional defunctionalisation and reversible degeneration of epidermal nerve endings for months. Analgesia after a single 8% patch (Qutenza) lasts up to 3 months. Low concentrations (0.025-0.075% creams) produce only a brief local effect and relieve itch. Systemic absorption through skin is clinically negligible when used correctly.
Second line
Capsaicin 8% patch (Qutenza) is an authorised option for postherpetic neuralgia when first-line therapy (gabapentin, pregabalin, amitriptyline) is insufficient. A single 60-minute application reduces pain by about 30% for 8-12 weeks. CG173 and SED (Sociedad Española del Dolor) recommend the patch in localised neuropathic pain and when oral medication is poorly tolerated. The patch is applied by a clinician or trained nurse under local skin anaesthesia.
Second line
Capsaicin 8% patch was -approved in 2020 for painful diabetic peripheral polyneuropathy of the feet. CG173 and redGDPS position the patch as second-line after gabapentinoids and duloxetine in patients with localised pain that does not extend above the knee. AEMPS authorised this indication in 2023. Low-dose 0.025-0.075% creams are not included in current recommendations for diabetic neuropathy – evidence quality is low.
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Low-dose capsaicin 0.025-0.075% creams for knee and hand osteoarthritis is an option with limited evidence. Cochrane (Derry 2017): the effect is small, clinically marginal and evidence quality is low. and SER osteoarthritis guidelines do not list capsaicin as first line; they recommend topical NSAIDs, paracetamol and, for knee osteoarthritis, duloxetine or intra-articular corticosteroids. Use can be discussed when topical NSAIDs are not tolerated, but the effect is limited and burning often leads patients to discontinue.
Not recommended
Capsaicin is a selective TRPV1 agonist with proven efficacy only in neuropathic pain as the high-dose 8% patch (Qutenza). Low-dose warming creams with capsaicin (Espol, Nicoflex, several OTC combinations) are marketed for «back pain, osteochondrosis, muscle pain, bruises». Cochrane (Derry 2017) on topical capsaicin for chronic pain: evidence quality is low and the effect is clinically insignificant. AAOS, and SER do not include such creams in first-line recommendations for acute musculoskeletal pain. If a capsaicin cream was prescribed for acute back pain, osteochondrosis or a bruise, consider seeking a second opinion.
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FDA Category B. Systemic absorption through skin is minimal. The high-dose 8% patch is generally avoided in pregnancy due to lack of data; AEMPS considers short topical use of low-dose capsaicin compatible with gestation.
Hale L2. Systemic absorption with correct use is minimal; do not apply to the breast or nipple before feeding. The 8% patch is not used during lactation – no formal safety data exist.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Capsaicin is evaluated for the following indications with varying evidence strength: Postherpetic neuralgia (evidence tier A), Diabetic polyneuropathy (evidence tier B), Osteoarthritis (evidence tier C). See the full indication matrix with dosing and citations above on this page.
Common side effects of Capsaicin (≥ 1 in 100): Intense burning and pain at the application site (especially during the first 30 minutes of the 8% patch), Erythema and oedema, Itching, Transient blood pressure rise during patch application. See the Safety section for uncommon and serious reactions.
FDA category B. FDA Category B. Systemic absorption through skin is minimal. The high-dose 8% patch is generally avoided in pregnancy due to lack of data; AEMPS considers short topical use of low-dose capsaicin compatible with gestation.
Hale L2. Systemic absorption with correct use is minimal; do not apply to the breast or nipple before feeding. The 8% patch is not used during lactation – no formal safety data exist.
Capsaicin is contraindicated in: Hypersensitivity to capsaicin or excipients; Broken skin, eczema or weeping wounds at the application site; Children under 18 years for the 8% patch. Full list in the Safety section.