Abstract
Topical anesthetics have become valuable tools in the field of dermatology, especially in pediatric patients, who have particular need for such anesthesia. The ideal topical anesthetic should provide effective, painless cutaneous analgesia with quick onset, sufficient duration and minimal adverse effects. This article reviews the basic science concepts relevant to the safe and judicious use of topical anesthetic agents in children, examines the specific characteristics and practical uses of these agents, and discusses the various unique delivery systems currently available.
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References
Munch RT, Abolson KB. The development of local anesthesia. Rev Surg 1976; 13(6): 371–80
Miller RD. Anesthesia. 4th ed. New York: Churchill Livingston Inc., 1994
Ahlstrom KK, Frodel JL. Local anesthetics for facial plastic procedures. Otolaryngol Clin North Am 2002; 35(1): 29–53
Grekin RC, Auletta MJ. Local anesthesia in dermatologic surgery. J Am Acad Dermatol 1988; 19(4): 599–614
Adriani J, Dalili H. Penetration of local anesthetics through epithelial barriers. Anesth Analg 1971; 50(5): 834–41
Zelickson AS, Hartman JF. An electron microscopic study of normal human non-keratinizing oral mucosa. J Invest Dermatol 1962; 38: 99–107
Adriani J, Zepernick R. Clinical effectiveness of drugs used for topical anesthesia. JAMA 1964; 188: 711–6
Berde CB, Strichartz GR. Local anesthetics. In: Miller RD, editor. Anesthesia. 5th ed. New York: Churchill Livingston Inc., 2000
Wilder RT. Local anesthetics for the pediatric patient. Pediatr Clin North Am 2000; 47(3): 545–58
Covino BG. Local anesthesia. N Engl J Med 1972; 286(18): 975–83
Rylander E, Sjoberg I, Lillieborg S, et al. Local anesthesia of the genital mucosa with a lidocaine/prilocaine cream (EMLA) for laser treatment of condylomata accuminata: a placebo-controlled study. Obstet Gynecol 1990; 75(2): 302–6
AstraZeneca Pharmaceuticals. EMLA® (lidocaine 2.5% and prilocaine 2.5%) anesthetic disc and cream: prescribing information. Wilmington (DE): AstraZeneca Pharmaceuticals, 2003
Bjerring P, Arendt-Nielsen L. Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream. Br J Anaesth 1990; 64(2): 173–7
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
Russell SC, Doyle E. A risk-benefit assessment of topical percutaneous local anaesthetics in children. Drug Saf 1997; 16(4): 279–87
Eichenfield LF, Funk A, Fallon-Friedlander S, et al. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics 2002; 109(6): 1093–9
Lander J, Hodgins M, Nazarali S, et al. Determinants of success and failure of EMLA. Pain 1996; 64(1): 89–97
Kleiber C, Sorenson M, Whiteside K, et al. Topical anesthetics for intravenous insertion in children: a randomized equivalency study. Pediatrics 2002; 110(4): 758–61
Koppel RA, Coleman KM, Coleman WP. The efficacy of EMLA vs ELA-Max for pain relief in medium-depth chemical peeling: a clinical and histopathologic evaluation. Dermatol Surg 2000; 26(1): 61–4
Lok C, Paul C, Amblard P, et al. EMLA cream as a topical anesthetic for the repeated mechanical debridement of venous leg ulcers: a double-blind, placebo-controlled study. J Am Acad Dermatol 1999; 40(2): 208–13
Friedman PM, Fogelman JP, Nouri K, et al. Comparative study of the efficacy of four topical anesthetics. Dermatol Surg 1999; 25(12): 950–4
Taddio A, Ohlsson A, Einarson TR, et al. A systematic review of lidocaineprilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics 1998; 101(2): El
Zempsky WT, Karasaic RB. EMLA versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med 1997; 30(2): 163–6
Kundu S, Achar S. Principles of office anesthesia. Part II: topical anesthesia. Am Fam Physician 2002; 66(1): 99–102
Chen BK, Cunningham BB. Topical anesthetics in children: agents and techniques that equally comfort patients, parents and clinicians. Curr Opin Pediatr 2001; 13(4): 324–30
Chang PC, O’Connor G, Rogers PJC, et al. A multicenter randomized study of single-unit dose package of EMLA patch vs EMLA cream 5% for venipuncture in children. Can J Anaesth 1994; 41(1): 59–63
Halperin SA, McGrath P, Smith B, et al. Lidocaine-prilocaine patch decreases the pain associated with the subcutaneous administration of measles-mumps-rubella vaccine but does not adversely affect antibody response. J Pediatr 2000; 136(6): 789–94
Nilsson A, Engberg G, Henneberg S, et al. Inverse relationship between age-dependent erythrocyte activity of methaemoglobin reductase and prilocaineinduced methaemoglobinaemia during infancy. Br J Anaesth 1990; 64(1): 72–6
Brisman M, Ljung BML, Otterbom I, et al. Methaemoglobin formation after the use of EMLA cream in term neonates. Acta Paediatr 1998; 87(11): 1191–4
Frayling IM, Addison GM, Chattergee K, et al. Methaemoglobinemia in children with prilocaine-lignocaine cream. BMJ 1990; 301(6744): 153–4
Huang W, Vidimos A. Topical anesthetics in dermatology. J Am Acad Dermatol 2000; 43 (2 Pt 1): 286–98
Evers H, von Dardel O, Juhlin L, et al. Dermal effects of compositions based on the eutectic mixture of lignocaine and prilocaine (EMLA): studies in volunteers. Br J Anaesth 1985; 57(10): 997–1005
Calobrisi SD, Drolet BA, Esterly NB. Petichial eruption after application of EMLA cream. Pediatrics 1998; 101(3): 471–3
Godwin Y, Brotherston M. Hyperpigmentation following the use of EMLA cream. Br J Plast Surg 2001; 54(1): 82–3
Tourna S, Jackson J. Lidocaine and prilocaine toxicity in a patient receiving treatment for mollusca contagiosa. J Am Acad Dermatol 2001; 44(2 Suppl.): 399–400
Rincon E, Baker RL, Iglesias AJ, et al. CNS toxicity after topical application of ENLA cream on a toddler with molluscum contagiosum. Pediatr Emerg Care 2000; 16(4): 252–4
Boulinguez S, Sparsa A, Bouyssou-Gauthier ML, et al. Adverse effects with EMLA cream used as topical anesthetic for the mechanical debridement of leg ulcers. J Am Acad Dermatol 2000; 42(1): 146–8
Ferndale Laboratories. L.M.X.4™: information sheet. Ferndale (MI): Ferndale Laboratories, 2004
Hernandez E, Gonzalez S, Gonzalez E. Evaluation of topical anesthetics by laser-induced sensation: comparison of EMLA 5% cream and 40% lidocaine in acid mantle ointment. Lasers Surg Med 1998; 23(3): 167–71
Sobue K, Tsuda T, Yumoto M, et al. Skin analgesia with lidocaine tape prior to epidural blockade. Can J Anaesth 2003; 50(1): 95–6
Goodwin DP, McMeekin TO. A case of lidocaine absorption from topical administration of 40% lidocaine cream. J Am Acad Dermatol 1999; 41(2): 280–1
McCafferty DF, Woolfson AD, Boston V. In vivo assessment of the percutaneous local anesthetic preparations. Br J Anaesth 1989; 62(1): 17–21
McCafferty DF, Woolfson AD, Handley J, et al. Effect of percutaneous local anaesthetics on pain reduction during pulse dye laser treatment. Br J Anaesth 1997; 78(3): 286–9
Jain A, Rutter N. Does topical amethocaine gel reduce the pain of venipuncture in newborn infants? A randomized double blind controlled trial. Arch Dis Child Fetal Neonatal Ed 2000; 83(3): F207–10
Jain A, Rutter N. Topical amethocain gel in the newborn infant: how soon does it work and how long does it last? Arch Dis Child Fetal Neonatal Ed 2000; 83(3): F211–4
Foldvari M, Gesztes A, Mezei M. Dermal drug delivery by liposomal encapsulation: clinical and electron microscopic studies. J Microencapsulation 1990; 7(4): 479–89
Fisher R, Hung O, Mezei M, et al. Topical anaesthesia of intact skin: liposomeencapsulated tetracaine vs EMLA. Br J Anaesth 1998; 81(6): 972–3
McCafferty DF, Woolfson AD. New patch delivery system for percutaneous local anesthesia. Br J Anaesth 1993; 71(3): 370–4
Shomaker TS, Zhang J, Love G, et al. Evaluating skin anesthesia after administration of a local anesthetic system consisting of an S-Caine patch and a controlled heat-aided drug delivery (CHADD) patch in volunteers. Clin J Pain 2000; 16(3): 200–4
Bryan HA, Alster TS. The S-Caine peel: a novel topical anesthetic for cutaneous laser surgery. Dermatol Surg 2002; 28(11): 999–1003
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
Gebauer Company. Ethyl chloride: package insert. Cleveland (OH): Gebauer Company, 2003
Irsfeld S, Klement W, Lipfert P. Dermal anesthesia: comparison of EMLA cream with iontophoretic local anesthesia. Br J Anaesth 1993; 71(3): 375–8
Gangarosa Sr LP, Ozawa A, Ohkido M, et al. Iontophoresis for enhancing penetration of dermatologic and antiviral drugs. J Dermatol 1995; 22(11): 865–75
Rodriguez E, Jordan R. Contemporary trends in pediatric sedation and analgesia. Emerg Med Clin North Am 2002; 20(1): 199–222
Vinci RJ, Fish SS. Efficacy of topical anesthesia in children. Arch Pediatr Adolesc Med 1996; 150(5): 466–9
Vinci RJ, Fish S, Mirochnick M. Cocaine absorption after application of a viscous cocaine-containing TAC solution. Ann Emerg Med 1999; 34(4): 498–502
Maurice SC, O’Donnell JJ, Beattie TF. Emergency analgesia in the paediatric population. Part II: pharmacological methods of pain relief. Emerg Med J 2002; 19(2): 101–5
Bonadio WA, Wagner V. Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children. Pediatrics 1990; 86(6): 856–7
Bonadio WA, Wagner V. Adrenaline-cocaine gel topical anesthetic for dermal laceration repair in children. Ann Emerg Med 1992; 21(12): 1435–8
Ernst AA, Marvez-Valls E, Nick TG, et al. LAT (lidocaine-adrenaline-tetracaine) vs TAC (tetracaine-adrenaline-cocaine) for topical anesthesia in face and scalp lacerations. Am J Emerg Med 1995; 13(2): 151–4
Mofenson HC, Caraccio TR, Miller H, et al. Lidocaine toxicity from topical mucosal application with a review of the clinical pharmacology of lidocaine. Clin Pediatr (Phila) 1983; 22(3): 190–2
AstraZeneca Pharmaceuticals. Xylocaine® (lidocaine): package insert: liquid, viscous solution, ointment. Wilmington (DE): AstraZeneca Pharmaceuticals, 2003
Gunaratnam NT, Vasquez-Sequeiros E, Gostout CJ, et al. Methemoglobinemia related to topical benzocaine use: is it time to reconsider the empiric use of topical anesthesia before sedated EGD? Gastrointest Endosc 2000; 52(5): 692–3
Cooper HA. Methemoglobinemia caused by benzocaine topical spray. South Med J 1997; 90(9): 946–8
Dailey RH. Fatality secondary to misuse of TAC solution. Ann Emerg Med 1988; 17(2): 159–60
Alcon Laboratories. Alcaine® (proparacaine hydrochloride 0.5%): package insert. Humacao (PR): Alcon Laboratories, 2003
Liesegang TJ, Perniciaro C. Fingertip dermatitis in an ophthalmologist caused by proparacaine. Am J Ophthalmol 1999; 127(2): 240–1
Bartfield JM, Holmes TJ, Raccio-Robak N. A comparison of proparacaine and tetracaine eye anesthetics. Acad Emerg Med 1994; 1(4): 364–7
Barker W, Rodeheaver GT, Edgerton MT, et al. Damage to tissue defenses by a topical anesthetic agent. Ann Emerg Med 1982; 11(6): 307–10
de Jong RH. Toxic effects of local anesthetics. JAMA 1978; 239(12): 1166–8
Daya M, Burton B, Schleiss M, et al. Recurrent seizures following mucosal application of TAC. Ann Emerg Med 1988; 17(6): 646–8
Tukel SS. Effects of acetaminophen on methemoglobinemia, Superoxide dismutase and Na-K ATPase activities of human erythrocytes. Biochem Mol Biol Int 1995; 35(4): 719–24
Jakobson B, Nilsson A. Methemoglobinemia associated with a prilocaine-lidocaine cream and trimethoprim sulphamethoxazole: a case report. Acta Anaesthesiol Scand 1985; 29(4): 453–5
Frey B, Kehrer B. Toxic methemoglobinemia concentrations in premature infants after application of a prilocaine-containing cream and peridural prilocaine. Eur J Pediatr 1999; 158(10): 785–8
Whalen JD. Delayed-type hypersensitivity after subcutaneous administration of amide anesthetic. Arch Dermatol 1996; 132(10): 1256–7
Mackley CL, Marks JG. Delayed-type hypersensitivity to lidocaine. Arch Dermatol 2003; 139(3): 343–6
Curley RK, MacFarlane AW, King CM. Contact sensitivity to the amide anesthetics lidocaine, prilocaine and mepivicaine: case report and review of the literature. Arch Dermatol 1986; 122(8): 924–6
Marks JG, Eisner P, DeLeo VA. Contact and occupational dermatology. 3rd ed. St Louis (MO): Mosby, 2002: 5
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Shainhouse, T., Cunningham, B.B. Topical anesthetics. Am J Drug Deliv 2, 89–99 (2004). https://doi.org/10.2165/00137696-200402020-00002
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DOI: https://doi.org/10.2165/00137696-200402020-00002