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Topical Anesthesia

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Evidence-Based Procedural Dermatology

Abstract

Topical anesthetics offer effective, uniform skin anesthesia while avoiding the discomfort and needle anxiety associated with injected local anesthetics. In the context of dermatology, they may be used to provide primary anesthesia or as an adjuvant pretreatment for alternative locoregional anesthesia. Unlike traditional injection anesthetics, two or more agents are typically combined in a vehicle for topical use. Because efficacy, indications, contraindications, and application techniques vary for these combination agents, this chapter aims to review the most common FDA-approved agents with a focus on best available evidence.

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References

  1. Kumar M, Chawla R, Goyal M. Topical anesthesia. J Anaesthesiol Clin Pharmacol. 2015;31(4):450–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Young KD. Topical anaesthetics: what’s new? Arch Dis Child Educ Pract Ed. 2015;100(2):105–10.

    Article  PubMed  Google Scholar 

  3. Friedman PM, Fogelman JP, Levine VJ, Ashinoff R. Comparative study of three topical anesthetics after 30-minute application time. Lasers Surg Med. 2000;26(Supplement 12):19.

    Google Scholar 

  4. Ashinoff R, Geronemus RG. Effect of the topical anesthetic EMLA on the efficacy of pulsed dye laser treatment of port-wine stains. J Dermatol Surg Oncol. 1990;16(11):1008–11.

    Article  CAS  PubMed  Google Scholar 

  5. Mansell-Gregory M, Romanowski B. Randomised double blind trial of EMLA for the control of pain related to cryotherapy in the treatment of genital HPV lesions. Sex Transm Infect. 1998;74(4):274–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Holm J, Andrén B, Grafford K. Pain control in the surgical debridement of leg ulcers by the use of a topical lidocaine – prilocaine cream. EMLA Acta Derm Venereol. 1990;70(2):132–6.

    CAS  PubMed  Google Scholar 

  7. Blanke W, Hallern BV. Sharp wound debridement in local anaesthesia using EMLA cream: 6 years’ experience in 1084 patients. Eur J Emerg Med. 2003;10(3):229–31.

    Article  PubMed  Google Scholar 

  8. Eidelman A, Weiss JM, Lau J, Carr DB. Topical anesthetics for dermal instrumentation: a systematic review of randomized, controlled trials. Ann Emerg Med. 2005;46(4):343–51.

    Article  PubMed  Google Scholar 

  9. Friedman PM, Fogelman JP, Nouri K, Levine VJ, Ashinoff R. Comparative study of the efficacy of four topical anesthetics. Dermatol Surg. 1999;25(12):950–4.

    Article  CAS  PubMed  Google Scholar 

  10. Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T. A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth. 2004;14(12):977–82.

    Article  PubMed  Google Scholar 

  11. Alster T. Review of lidocaine/tetracaine cream as a topical anesthetic for dermatologic laser procedures. Pain Ther. 2013;2(1):11–9.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Galderma, USA. Pliaglis prescribing information. [Internet]. [cited 2016 Nov 22]. Available from: http://www.galdermausa.com/pdf/10156700-0407%20PLIAGLIS%20Package%20Insert.pdf

  13. Kim WO, Song BM, Kil HK. Efficacy and safety of a lidocaine/tetracaine medicated patch or peel for dermatologic procedures: a meta-analysis. Korean J Anesthesiol. 2012;62(5):435–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Doshi SN, Friedman PM, Marquez DK, Goldberg LH. Thirty-minute application of the S-Caine peel prior to nonablative laser treatment. Dermatol Surg. 2003;29(10):1008–11.

    PubMed  Google Scholar 

  15. Chen JZS, Alexiades-Armenakas MR, Bernstein LJ, Jacobson LG, Friedman PM, Geronemus RG. Two randomized, double-blind, placebo-controlled studies evaluating the S-Caine Peel for induction of local anesthesia before long-pulsed Nd:YAG laser therapy for leg veins. Dermatol Surg. 2003;29(10):1012–8.

    PubMed  Google Scholar 

  16. Jih MH, Friedman PM, Sadick N, Marquez DK, Kimyai-Asadi A, Goldberg LH. 60-minute application of S-Caine Peel prior to 1,064 nm long-pulsed Nd:YAG laser treatment of leg veins. Lasers Surg Med. 2004;34(5):446–50.

    Article  PubMed  Google Scholar 

  17. Alster TS, Lupton JR. Evaluation of a novel topical anesthetic agent for cutaneous laser resurfacing: a randomized comparison study. Dermatol Surg. 2002;28(11):1004–6. discussion 1006.

    PubMed  Google Scholar 

  18. Cohen JL. Pain management with a topical lidocaine and tetracaine 7%/7% cream with laser dermatologic procedures. J Drugs Dermatol. 2013;12(9):986–9.

    CAS  PubMed  Google Scholar 

  19. Eidelman A, Weiss JM, Enu IK, Lau J, Carr DB. Comparative efficacy and costs of various topical anesthetics for repair of dermal lacerations: a systematic review of randomized, controlled trials. J Clin Anesth. 2005;17(2):106–16.

    Article  CAS  PubMed  Google Scholar 

  20. Franchi M, Cromi A, Scarperi S, Gaudino F, Siesto G, Ghezzi F. Comparison between lidocaine-prilocaine cream (EMLA) and mepivacaine infiltration for pain relief during perineal repair after childbirth: a randomized trial. Am J Obstet Gynecol. 2009;201(2):186.e1–5.

    Article  CAS  Google Scholar 

  21. Jones TM, Nandapalan V. Manipulation of the fractured nose: a comparison of local infiltration anaesthesia and topical local anaesthesia. Clin Otolaryngol Allied Sci. 1999;24(5):443–6.

    Article  CAS  PubMed  Google Scholar 

  22. Goodacre TE, Sanders R, Watts DA, Stoker M. Split skin grafting using topical local anaesthesia (EMLA): a comparison with infiltrated anaesthesia. Br J Plast Surg. 1988;41(5):533–8.

    Article  CAS  PubMed  Google Scholar 

  23. Ferguson C, Loryman B, Body R. Best evidence topic report. Topical anaesthetic versus lidocaine infiltration to allow closure of skin wounds in children. Emerg Med J. 2005;22(7):507–9.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB. Topical anaesthetics for pain control during repair of dermal laceration. Cochrane Database Syst Rev. 2011;(6):CD005364.

    Google Scholar 

  25. Hegenbarth MA, Altieri MF, Hawk WH, Greene A, Ochsenschlager DW, O’Donnell R. Comparison of topical tetracaine, adrenaline, and cocaine anesthesia with lidocaine infiltration for repair of lacerations in children. Ann Emerg Med. 1990;19(1):63–7.

    Article  CAS  PubMed  Google Scholar 

  26. Priestley S, Kelly A-M, Chow L, Powell C, Williams A. Application of topical local anesthetic at triage reduces treatment time for children with lacerations: a randomized controlled trial. Ann Emerg Med. 2003;42(1):34–40.

    Article  PubMed  Google Scholar 

  27. Smith GA, Strausbaugh SD, Harbeck-Weber C, Cohen DM, Shields BJ, Powers JD, et al. Prilocaine-phenylephrine and bupivacaine-phenylephrine topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations. Am J Emerg Med. 1998;16(2):121–4.

    Article  CAS  PubMed  Google Scholar 

  28. Zempsky WT, Karasic RB. EMLA versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med. 1997;30(2):163–6.

    Article  CAS  PubMed  Google Scholar 

  29. Burkhart CG, Burkhart CN. Decreased efficacy of topical anesthetic creams in presence of benzoyl peroxide. Dermatol Surg. 2005;31(11 Pt 1):1479–80.

    CAS  PubMed  Google Scholar 

  30. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg. 2012;38(5):709–21.

    Article  CAS  PubMed  Google Scholar 

  31. Railan D, Alster TS. Use of topical lidocaine for cosmetic dermatologic procedures. J Drugs Dermatol. 2007;6(11):1104–8.

    PubMed  Google Scholar 

  32. Blickenstaff NR, Coman G, Blattner CM, Andersen R, Maibach HI. Biology of percutaneous penetration. Rev Environ Health. 2014;29(3):145–55.

    Article  CAS  PubMed  Google Scholar 

  33. Chiang A, Tudela E, Maibach HI. Percutaneous absorption in diseased skin: an overview. J Appl Toxicol. 2012;32(8):537–63.

    Article  CAS  PubMed  Google Scholar 

  34. Akorn – Lidocaine 2.5% and Prilocaine 2.5% Cream [Internet]. [cited 2016 Nov 23]. Available from: http://www.akorn.com/prod_detail.php?ndc=50383-667-30

  35. Wahlgren CF, Quiding H. Depth of cutaneous analgesia after application of a eutectic mixture of the local anesthetics lidocaine and prilocaine (EMLA cream). J Am Acad Dermatol. 2000;42(4):584–8.

    Article  CAS  PubMed  Google Scholar 

  36. Benson HAE. Transfersomes for transdermal drug delivery. Expert Opin Drug Deliv. 2006;3(6):727–37.

    Article  CAS  PubMed  Google Scholar 

  37. Fisher R, Hung O, Mezei M, Stewart R. Topical anaesthesia of intact skin: liposome-encapsulated tetracaine vs EMLA. Br J Anaesth. 1998;81(6):972–3.

    Article  CAS  PubMed  Google Scholar 

  38. Friedman PM, Mafong EA, Friedman ES, Geronemus RG. Topical anesthetics update: EMLA and beyond. Dermatol Surg. 2001;27(12):1019–26.

    CAS  PubMed  Google Scholar 

  39. Russell SC, Doyle E. A risk-benefit assessment of topical percutaneous local anaesthetics in children. Drug Saf. 1997;16(4):279–87.

    Article  CAS  PubMed  Google Scholar 

  40. Kundu S, Achar S. Principles of office anesthesia: part II. Topical anesthesia. Am Fam Physician. 2002;66(1):99–102.

    PubMed  Google Scholar 

  41. Berkman S, MacGregor J, Alster T. Adverse effects of topical anesthetics for dermatologic procedures. Expert Opin Drug Saf. 2012;11(3):415–23.

    Article  CAS  PubMed  Google Scholar 

  42. Dailey RH. Fatality secondary to misuse of TAC solution. Ann Emerg Med. 1988;17(2):159–60.

    Article  CAS  PubMed  Google Scholar 

  43. Tadicherla S, Berman B. Percutaneous dermal drug delivery for local pain control. Ther Clin Risk Manag. 2006;2(1):99–113.

    CAS  PubMed  PubMed Central  Google Scholar 

  44. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg. 2009;108(3):837–45.

    Article  CAS  PubMed  Google Scholar 

  45. LIDODERM® (Lidocaine Patch 5%) [Internet]. [cited 2016 Nov 24]. Available from: http://www.endo.com/File%20Library/Products/Prescribing%20Information/LIDODERM_prescribing_information.html

  46. Singer AJ, Shallat J, Valentine SM, Doyle L, Sayage V, Thode HC. Cutaneous tape stripping to accelerate the anesthetic effects of EMLA cream: a randomized, controlled trial. Acad Emerg Med. 1998;5(11):1051–6.

    Article  CAS  PubMed  Google Scholar 

  47. Yun PL, Tachihara R, Anderson RR. Efficacy of erbium:yttrium-aluminum-garnet laser-assisted delivery of topical anesthetic. J Am Acad Dermatol. 2002;47(4):542–7.

    Article  PubMed  Google Scholar 

  48. Irsfeld S, Klement W, Lipfert P. Dermal anaesthesia: comparison of EMLA cream with iontophoretic local anaesthesia. Br J Anaesth. 1993;71(3):375–8.

    Article  CAS  PubMed  Google Scholar 

  49. Masud S, Wasnich RD, Ruckle JL, Garland WT, Halpern SW, Mee-Lee D, et al. Contribution of a heating element to topical anesthesia patch efficacy prior to vascular access: results from two randomized, double-blind studies. J Pain Symptom Manag. 2010;40(4):510–9.

    Article  Google Scholar 

  50. Synera | (Lidocaine Tetracaine) Topical Patch: Official Website [Internet]. Synera®. [cited 2016 Nov 23]. Available from: http://www.synera.com/wp-content/uploads/2015/03/SYNERA_PI.pdf.

  51. Marriott TB, Charney MR, Stanworth S. Effects of application durations and heat on the pharmacokinetic properties of drug delivered by a lidocaine/tetracaine patch: a randomized, open-label, controlled study in healthy volunteers. Clin Ther. 2012;34(10):2174–83.

    Article  CAS  PubMed  Google Scholar 

  52. Zempsky WT, Sullivan J, Paulson DM, Hoath SB. Evaluation of a low-dose lidocaine iontophoresis system for topical anesthesia in adults and children: a randomized, controlled trial. Clin Ther. 2004;26(7):1110–9.

    Article  CAS  PubMed  Google Scholar 

  53. Wallace MS, Ridgeway B, Jun E, Schulteis G, Rabussay D, Zhang L. Topical delivery of lidocaine in healthy volunteers by electroporation, electroincorporation, or iontophoresis: an evaluation of skin anesthesia. Reg Anesth Pain Med. 2001;26(3):229–38.

    CAS  PubMed  Google Scholar 

  54. Nestor MS. Safety of occluded 4% liposomal lidocaine cream. J Drugs Dermatol. 2006;5(7):618–20.

    PubMed  Google Scholar 

  55. Lidosite (Lidocaine /Epinephrine Iontophoresis) – Drug info, side effects, research, clinical trials [Internet]. [cited 2016 Nov 23]. Available from: http://www.druglib.com/druginfo/lidosite/.

  56. Zempsky WT, Robbins B, McKay K. Reduction of topical anesthetic onset time using ultrasound: a randomized controlled trial prior to venipuncture in young children. Pain Med Malden Mass. 2008;9(7):795–802.

    Article  Google Scholar 

  57. Duan D, Moeckly C, Gysbers J, Novak C, Prochnow G, Siebenaler K, et al. Enhanced delivery of topically-applied formulations following skin pre-treatment with a hand-applied, plastic microneedle array. Curr Drug Deliv. 2011;8(5):557–65.

    Article  CAS  PubMed  Google Scholar 

  58. Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK. Jet injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care. 2008;24(8):511–5.

    Article  PubMed  Google Scholar 

  59. Lawson RA, Smart NG, Gudgeon AC, Morton NS. Evaluation of an amethocaine gel preparation for percutaneous analgesia before venous cannulation in children. Br J Anaesth. 1995;75(3):282–5.

    Article  CAS  PubMed  Google Scholar 

  60. Tran AN, Koo JY. Risk of systemic toxicity with topical lidocaine/prilocaine: a review. J Drugs Dermatol. 2014;13(9):1118–22.

    CAS  PubMed  Google Scholar 

  61. Boonsiri M, Marks KC, Ditre CM. Benzocaine/Lidocaine/Tetracaine cream: report of corneal damage and review. J Clin Aesthetic Dermatol. 2016;9(3):48–50.

    Google Scholar 

  62. Cortazzo JA, Lichtman AD. Methemoglobinemia: a review and recommendations for management. J Cardiothorac Vasc Anesth. 2014;28(4):1043–7.

    Article  CAS  PubMed  Google Scholar 

  63. Chowdhary S, Bukoye B, Bhansali AM, Carbo AR, Adra M, Barnett S, et al. Risk of topical anesthetic-induced methemoglobinemia: a 10-year retrospective case-control study. JAMA Intern Med. 2013;173(9):771–6.

    Article  CAS  PubMed  Google Scholar 

  64. Mackie BS, Mackie LE. The PABA story. Australas J Dermatol. 1999;40(1):51–3.

    Article  CAS  PubMed  Google Scholar 

  65. Kravitz ND. The use of compound topical anesthetics: a review. J Am Dent Assoc 1939. 2007;138(10):1333–39; quiz 1382.

    Article  PubMed  Google Scholar 

  66. Research C for DE and. Postmarket Drug Safety Information for Patients and Providers – Public health advisory: life-threatening side effects with the use of skin products containing numbing ingredients for cosmetic procedures [Internet]. [cited 2016 Nov 23]. Available from: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm054718.htm

  67. Murase JE, Heller MM, Butler DC. Safety of dermatologic medications in pregnancy and lactation: part I pregnancy. J Am Acad Dermatol. 2014;70(3):401.e1–14. quiz 415.

    Article  CAS  Google Scholar 

  68. Ortega D, Viviand X, Lorec AM, Gamerre M, Martin C, Bruguerolle B. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand. 1999;43(4):394–7.

    Article  CAS  PubMed  Google Scholar 

  69. Kouba DJ, LoPiccolo MC, Alam M, Bordeaux JS, Cohen B, Hanke CW, et al. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol. 2016;74(6):1201–19.

    Article  PubMed  Google Scholar 

  70. Butler DC, Heller MM, Murase JE. Safety of dermatologic medications in pregnancy and lactation: Part II Lactation. J Am Acad Dermatol. 2014;70(3):417.e1–10. quiz 427.

    Article  CAS  Google Scholar 

  71. American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776–89.

    Article  Google Scholar 

  72. Irkoren S, Ozkan HS, Karaca H. A clinical comparison of EMLA cream and ethyl chloride spray application for pain relief of forehead botulinum toxin injection. Ann Plast Surg. 2015;75(3):272–4.

    Article  CAS  PubMed  Google Scholar 

  73. Robinson PA, Carr S, Pearson S, Frampton C. Lignocaine is a better analgesic than either ethyl chloride or nitrous oxide for peripheral intravenous cannulation. Emerg Med Austral. 2007;19(5):427–32.

    Article  Google Scholar 

  74. Armstrong P, Young C, McKeown D. Ethyl chloride and venepuncture pain: a comparison with intradermal lidocaine. Can J Anaesth. 1990;37(6):656–8.

    Article  CAS  PubMed  Google Scholar 

  75. Selby IR, Bowles BJ. Analgesia for venous cannulation: a comparison of EMLA (5 minutes application), lignocaine, ethyl chloride, and nothing. J R Soc Med. 1995;88(5):264–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  76. Soueid A, Richard B. Ethyl chloride as a cryoanalgesic in pediatrics for venipuncture. Pediatr Emerg Care. 2007;23(6):380–3.

    Article  PubMed  Google Scholar 

  77. Meechan JG, Gowans AJ, Welbury RR. The use of patient-controlled transcutaneous electronic nerve stimulation (TENS) to decrease the discomfort of regional anaesthesia in dentistry: a randomised controlled clinical trial. J Dent. 1998;26(5–6):417–20.

    Article  CAS  PubMed  Google Scholar 

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Phillips, C.B., McEnery-Stonelake, M., Huang, C.C. (2019). Topical Anesthesia. In: Alam, M. (eds) Evidence-Based Procedural Dermatology. Springer, Cham. https://doi.org/10.1007/978-3-030-02023-1_33

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