Have you noticed the " keep out of reach of children" warning on topical muscle pain relief cream on Bengay, Tiger Balm or Icy Hot? Most of them do not give much thought when we lather ourselves on these topical pain relievers, thinking its better than taking a tablet. But you might be wrong there. They are not always harmless.
In a rare and tragic case from 2007, 17-year-old track athlete Arielle Newman of Staten Island, New York, died in April after her body absorbed lethal levels of methyl salicylate, the active ingredient in many over-the-counter (OTC) muscle pain creams and topical analgesics such as Bengay, Icy Hot, and Tiger Balm. This case drew attention to the sometimes overlooked systemic risks associated with excessive use of topical pain relievers.
Methyl salicylate, also known as oil of wintergreen, is a salicylate compound that produces a cooling or warming sensation on the skin and provides minor relief from musculoskeletal aches. Although designed for external use only, methyl salicylate can be absorbed into the bloodstream, especially when used repeatedly or over large skin areas. Systemic absorption of salicylates can lead to salicylate toxicity, a serious medical condition.
If ingested, it is rapidly absorbed through the gastrointestinal tract, and even small amounts can deliver a dose of salicylate equivalent to many aspirin tablets, for example, a single teaspoon of pure oil of wintergreen can contain the salicylate equivalent of dozens of aspirin tablets. In children, as little as 4 mL may be fatal because their smaller body size cannot tolerate high systemic salicylate levels. Once absorbed, salicylates disrupt normal metabolic and respiratory processes, and poisoning symptoms can include nausea, vomiting, rapid breathing, tinnitus (ringing in the ears), confusion, seizures, and potentially death. Products containing methyl salicylate pose a risk for systemic toxicity if misused or ingested, which is why such products are recommended to be kept out of reach of children and in child-resistant containers.
According to the New York City medical examiner’s office reported by associate press,3 Newman applied multiple products containing methyl salicylate, including muscle cream and adhesive pads on her legs between track events and competitions. The medical examiner reported that she used these products “to excess,” leading to unusually high levels of methyl salicylate in her body. While deaths from topical analgesics are extremely rare, this was the first reported instance by that office.
Experts noted that chronic use and factors such as exercise, heat and increased skin perfusion may have accentuated absorption, contributing to systemic toxicity. The medical examiner’s spokeswoman, Ellen Borakove, stated that the chemicals were absorbed over time rather than from a single instance of misuse.
Salicylates are a class of compounds related to aspirin, and their presence in the bloodstream at high concentrations can cause serious effects.
Most salicylate toxicity cases are associated with oral ingestion of drugs, but methyl salicylate’s lipophilic nature can facilitate percutaneous absorption, particularly with frequent reapplications, use on large body areas, or concurrent heat exposure from exercise.
Following the investigation, Johnson & Johnson, the manufacturer of Bengay, had issued a statement expressing sympathy to Newman’s family. The company reiterated that when used as directed, its product is “safe and effective” for relieving minor muscle and joint pain. The standard label instructions state that topical analgesics should be applied no more than three or four times daily and that users should discontinue use and consult a physician if pain persists more than 7 days.
Arielle Newman’s death highlights the fact that “over-the-counter” does not automatically mean “risk-free.” Topical pain relievers, like all medications, carry potential for adverse effects if misused. While serious toxicity from methyl salicylate is exceedingly uncommon, clinicians remind patients to follow label directions and consult healthcare professionals when using any medication frequently or in combination with other treatments.
References
Chin RL, Olson KR, Dempsey D. Salicylate toxicity from ingestion and continued dermal absorption. Cal J Emerg Med. 2007 Feb;8(1):23-5. PMID: 20440389; PMCID: PMC2859737. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859737/.
Hack, Jason B., MD. 2025. “Toxicology Answer: Oil of Wintergreen.” ACEP Now, October 28, 2025. https://www.acepnow.com/article/toxicology-answer-oil-of-wintergreen/.
Associated Press. 2007. “Teen Dies After Using Too Much Muscle Cream.” Action News 5, June 10, 2007. https://www.actionnews5.com/story/6636388/teen-dies-after-using-too-much-muscle-cream/.
