Topical Anesthetics for Minor Procedures

Introduction to Topical Anesthetics

The American Academy of Dermatology recommends EMLA cream as the preferred topical anesthetic for minor procedures due to its superior efficacy and established safety profile 1, 2, 3

The American Academy of Dermatology recommends topical anesthetics as first-line for nonablative laser treatments, with a Strength A recommendation for children's laceration repair and a Strength C recommendation for other uses 1, 3
The American Academy of Dermatology recommends topical anesthetics for minor office procedures, including skin biopsy, small excisions, filler and botulinum toxin injections 1, 2, 3
The American Academy of Dermatology recommends topical anesthetics for reducing pain of infiltrative anesthetic injection 1, 3
The American Academy of Dermatology recommends topical anesthetics for dermal laceration repair in children 1, 3

Methemoglobinemia is a possible risk with EMLA (lidocaine/prilocaine mixture) 4
EMLA is only for use on intact skin 4
Pediatric patients (<12 months or <10 kg) require dose reduction 5, 6
Infants under 6 months should have doses reduced by 30% 5
Topical lidocaine is safe for pregnant or nursing women, but insufficient evidence exists for other topical anesthetics including EMLA 1, 2, 3

EMLA requires 60 minutes of application under occlusive dressing to reach full effectiveness 5, 6
Liposomal 4% lidocaine (LMX4) achieves anesthesia in 30 minutes 5, 6
The maximum safe dose in adults is 4.5 mg/kg without epinephrine or 7.0 mg/kg with epinephrine 5

Choose EMLA when time permits 60-minute application 5, 6
Choose EMLA when patient is not pregnant/nursing 1, 2, 3
Choose lidocaine formulations when faster onset is required (30 minutes with LMX4) 5, 6
Choose lidocaine formulations when patient is pregnant or nursing 1, 2, 3
Choose lidocaine formulations when methemoglobinemia risk is a concern 4

Noncocaine anesthetics are preferred over cocaine formulations due to lower cost and reduced adverse effects 2, 4