American Academy of Dermatology

• Guidelines for the use of local anesthesia in office-based dermatologic surgery.

• GUIDELINE SUMMARY
 
• NGC:010993
 
• 2016 JUN

Guidelines for the use of local anesthesia in office-based dermatologic surgery.

Recommendations

Major Recommendations

Level of evidence grades (I-III) and strength of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

Recommendations for the Use of Topical Anesthesia in Dermatologic Surgery

• Noncocaine formulations are preferred over cocaine formulations and recommended for use in office-based procedures.
• Topical agents are recommended as a first-line method of anesthesia for nonablative laser treatments.
• Topical anesthesia can be used for performing office-based procedures, such as skin biopsy, small excisions, and filler and botulinum toxin injections.
• The use of topical anesthetic agents is recommended to lessen the pain of injection and reduce the dose of infiltration anesthesia needed for larger procedures.
• Topical lidocaine is safe for use on pregnant or nursing women, but there is insufficient evidence to recommend use of other topical anesthetics.
  • Elective procedures and those not of urgent medical necessity requiring topical lidocaine in pregnant women should be postponed until after delivery.
  • Procedures of urgent medical necessity should be delayed until at least the second trimester when possible.
• Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.
• For more extensive surgery, the combination of topical and infiltration anesthesia should be considered as an alternate to sedation or general anesthesia in pediatric patients.

Strength of Recommendations for Use of Topical Anesthesia in Dermatologic Surgery

Recommendation	Strength of Recommendation	Level of Evidence	References
Use of noncocaine topical anesthetics	A	II	Eidelman et al., 2005
Topical anesthesia as the first-line method for nonablative laser treatments	C	III	Bryan & Alster, 2002; Kilmer et al., 2003
Topical anesthesia for use in minor skin procedures in adults	C	III	Bryan & Alster, 2002; Kilmer et al., 2003; Franchi et al., 2009; Jones & Nandapalan, 1999; Goodacre et al., 1988; Russell, Desmond, & Fox, 1988; Ferguson, Loryman, & Body, 2005; Hallen, Ljunghall, & Wallin, 1987; Gupta & Sibbald, 1996
Topical anesthesia to reduce the pain of local anesthetic injection	C	III	Expert opinion
Use of limited amounts of topical lidocaine in pregnant and nursing women	C	III	Murase, Heller, & Butler, 2014; Gormley, 1990; Richards & Stasko, 2002; Butler, Heller, & Murase, 2014
Postpone use of topical anesthesia until after delivery or second trimester when possible	C	III	Expert opinion
Against use of nonlidocaine topical anesthetics in pregnant or nursing women	C	III	Expert opinion
Use of topical anesthesia as the first-line method for repair of dermal lacerations in children	A	I, II	Ferguson, Loryman, & Body, 2005; Bonadio & Wagner, 1988; Hegenbarth et al., 1990; Smith et al., 1998; Smith et al., 1996; Smith & Barry, 1990; Zempsky & Karasic, 1997
Use of topical anesthesia as the first-line method for other minor procedures in children	C	III	Expert opinion
Adjunctive use of topical anesthesia to minimize discomfort of infiltrative anesthesia in children	C	III	Expert opinion
Topical and infiltrative anesthesia used as an alternate to sedation and general anesthesia in children	C	III	Ferguson, Loryman, & Body, 2005; Bonadio & Wagner, 1988; Hegenbarth et al., 1990; Smith et al., 1998; Smith et al., 1996; Smith & Barry, 1990; Zempsky & Karasic, 1997; Pierluisi & Terndrup, 1989; Priestley et al., 2003

Recommendations for the Use of Local Infiltrative Anesthesia in Dermatologic Surgery

• Infiltrative anesthesia is safe and recommended for office-based dermatologic procedures, including but not limited to obtaining a biopsy specimen, excision, wound closure, tissue rearrangement, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing.
• Infiltrative anesthesia may be combined with other forms of local anesthesia for larger or more complex cutaneous procedures, including but not limited to:
  • Full-face ablative laser resurfacing, combined with topical and nerve block anesthesia
  • Follicular unit hair transplantation, combined with tumescent local anesthesia.
• The maximum safe dose of local infiltrated anesthesia is unknown.
• For adults, no more than 4.5 mg/kg of lidocaine and 7.0 mg/kg of lidocaine with epinephrine should be administered in a single treatment.
• For children, no more than 1.5-2.0 mg/kg of lidocaine and 3.0-4.5 mg/kg of lidocaine with epinephrine should be administered in a single treatment.
• For a multistage procedure, such as Mohs micrographic surgery, a maximum dose of local infiltrative anesthesia of 50 mL of 1% lidocaine solution (500 mg) delivered over several hours is recommended.
• Use of either ester-type local anesthetics, bacteriostatic normal saline, or 1% diphenhydramine is suggested as an alternate form of local infiltration anesthesia for patients with true allergy to lidocaine.
• Steps recommended to decrease the risk of local anesthetic systemic toxicity:
  • Use the lowest effective dose of local anesthetic.
  • Aspirate the needle/catheter prior to each injection to avoid introducing the drug directly into a vessel.
  • Use incremental injections of anesthetic.
  • Continually assess and communicate with the patient to monitor for signs of early toxicity.

Strength of Recommendations for the Use of Local Infiltrative Anesthesia in Dermatologic Surgery

Recommendation	Strength of Recommendation	Level of Evidence	References
Use of local infiltrative anesthesia for obtaining a biopsy specimen, excision, wound closure, tissue rearrangement, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing	C	III	Expert opinion
Combining methods of local anesthesia for full-face ablative laser and follicular unit hair transplantation	C	III	Expert opinion
Maximum dose of 4.5 mg/kg of lidocaine and 7.0 mg/kg of lidocaine with epinephrine for adults	C	III	Hancox et al., 2004; Klein, 1993; Drake et al., 1995
Maximum dose of 1.5-2.0 mg/kg of lidocaine and 3.0-4.5 mg/kg of lidocaine with epinephrine for children	C	III	Hancox et al., 2004
Max dose of 500 mg of lidocaine for a multistage Mohs micrographic surgery	B	II	Alam et al., 2010
Use of ester type local anesthetics for patients with lidocaine allergy	C	III	Bhole et al., 2012
Use of diphenhydramine for patients with lidocaine allergy	C	III	Green, Rothrock, & Gorchynski, 1994; Xia et al., 2002
Use of bacteriostatic normal saline for patients with lidocaine allergy	C	III	Bartfield, Jandreau, & Raccio-Robak, 1998
Prevention of local anesthetic systemic toxicity	A	I, II	Neal et al., 2010; Neal, Mulroy, & Weinberg, 2012; Mercado & Weinberg, 2011

Recommendations for Mixing and the Use of Additives to Local Infiltrative Anesthesia in Dermatologic Surgery

Epinephrine

• The addition of epinephrine to local infiltration anesthesia is safe and recommended for use on the ear, nose, hand, feet, and digits.
• The addition of epinephrine to local infiltration anesthesia may be considered for use during procedures on the penis.
• Local infiltrative anesthesia with epinephrine may be used in small amounts in women who are pregnant:
  • Elective procedures and those not of urgent medical necessity requiring lidocaine with epinephrine should be postponed until after delivery.
  • Procedures of urgent medical necessity should be delayed until the second trimester when possible.
  • In case of doubt, consult with the patient's obstetrician.
• Local infiltrative anesthesia with epinephrine may be administered to patients with stable cardiac disease. If uncertain of a patient's ability to tolerate epinephrine, consult with the patient's cardiologist.
• Use of the lowest effective concentration of epinephrine to provide pain control and vasoconstriction in local infiltrative anesthesia is recommended.

Hyaluronidase

• Hyaluronidase may be used as an additive to local infiltration anesthesia to ease diffusion and reduce contour distortion, yet there are insufficient data to support a recommendation for its routine use in dermatologic surgery.
• Hyaluronidase should not be administered to patients with a known bee venom allergy.

Buffering

• The addition of sodium bicarbonate to local anesthetic, particularly lidocaine with epinephrine, is recommended to decrease the pain of delivery by subcutaneous or intradermal infiltration.
• Preinjection of buffered lidocaine solution is suggested to reduce the pain of bupivacaine infiltration.

Mixing Local Anesthetics

It is unclear whether mixing multiple anesthetics for local infiltration poses further benefit over use of a single agent.

Strength of Recommendations for Mixing and the Use of Additives to Local Infiltrative Anesthesia in Dermatologic Surgery

Recommendation	Strength of Recommendation	Level of Evidence	References
Addition of epinephrine to local anesthesia on the ear, nose, and digits	A	I, II	Altinyazar et al., 2004; Chowdhry et al., 2010; Denkler, 2001; Denkler, 2005; Häfner et al., 2008; Krunic et al., 2004; Lalonde et al., 2005; Radovic, Smith, & Shumway, 2003; Sonohata et al., 2012; Wilhelmi et al., 2001; Häfner, Rocken, & Breuninger, 2005
Addition of epinephrine to local anesthesia on the penis	B	II	Schnabl et al., 2014
Addition of epinephrine to local anesthesia in women who are pregnant or nursing	B	II	Murase, Heller, & Butler, 2014
Addition of epinephrine to local anesthesia in patients with stable cardiac disease	B	I, II	Serrera Figallo et al., 2012; Niwa et al., 2001
Addition of epinephrine to local infiltrative anesthesia at the lowest effective concentration	B	II, III	Dunlevy, O'Malley, & Postma 1996; Gessler et al., 2001; Liu et al., 1995
Against addition of hyaluronidase to local anesthesia in patients with bee venom allergy	B	II	Kirby et al., 2001
Against use of hyaluronidase to reduce tissue distortion and improve undermining	C	III	Clark & Mellette, 1994; Landsman & Mandy, 1991
Addition of sodium bicarbonate to reduce pain of local anesthetic infiltration	A	I, II	Masters, 1998; Stewart et al., 1990; Stewart, Cole, & Klein, 1989; Welch et al., 2012; Burns et al., 2006
Preinjection of buffered lidocaine to reduce pain of bupivacaine injection	C	III	Expert opinion
Mixing multiple anesthetics for the same procedure	C	II	Gadsden et al., 2011; Lai, Sutton, & Nicholson, 2003; Nicholson, Sutton, & Hall, 2000; Ozdemir et al., 2004; Ribotsky, Berkowitz, & Montague, 1996; Seow et al., 1982; Sweet, Magee, & Holland, 1982; van den Berg & Montoya-Pelaez, 2001

Recommendations for Minimizing Pain of Administration of Local Infiltration Anesthesia and Alternate Methods of Analgesia in Dermatologic Surgery

• Slow rate of infiltration, vibration of the skin, use of a warm solution, or cold air skin cooling should be considered to decrease the pain of local anesthetic injection.
• It is unclear whether pretreatment with ethyl chloride spray, preinjection with normal saline, or verbal distraction decreases the pain of local anesthetic infiltration.
• There is contradictory evidence regarding the effectiveness of ethyl chloride, and its use as a sole method for analgesia in dermatologic procedures should not be considered.
• Cold air skin cooling may be considered to reduce patient discomfort during nonablative laser therapy.
• Use of a skin-vibrating device may be considered to help decrease the pain of botulinum toxin injection.

Strength of Recommendations for Minimizing Pain of Administration of Local Infiltration Anesthesia and Alternate Methods of Analgesia in Dermatologic Surgery

Recommendation	Strength of Recommendation	Level of Evidence	References
Slow rate of infiltration, vibration of the skin, use of a warm solution, and cold air skin cooling are recommended to decrease the pain of local anesthetic injection.	B	II	Fosko, Gibney, & Harrison, 1998; Kaplan & Moy, 1996; Scarfone, Jasani, & Gracely, 1998; Al-Qarqaz et al., 2012; Fayers, Morris, & Dolman, 2010
Pretreatment with ethyl chloride spray, preinjection with normal saline, or verbal distraction to decrease the pain of local anesthetic infiltration	C	III	Expert opinion; Swinehart, 1992
Ethyl chloride as an analgesic for dermatologic procedures.	C	III	Armstrong, Young, & McKeown, 1990; Robinson et al., 2007; Selby & Bowles, 1995; Soueid & Richard, 2007; Yoon et al., 2008; White et al., 1999
Cold air skin cooling to reduce patient discomfort during nonablative laser therapy	B	II	Hammes & Raulin, 2005; Raulin, Greve, & Hammes, 2000
Use of a skin-vibrating device to decrease the pain of botulinum toxin injection into glabellar rhytides	B	II	Sharma, Czyz, & Wulc, 2011

Recommendations for Nerve Blocks in Dermatologic Surgery

• Regional cutaneous nerve block anesthesia is recommended for ablative laser resurfacing of the face and botulinum toxin injection of the palm
• Nerve block should be considered as an alternative or in addition to infiltrative anesthesia for procedures on the face, hands, feet, and digits, and may provide the benefit of decreased tissue swelling/distortion, prolong anesthesia, and reduce postoperative discomfort for the patient

Strength of Recommendations for Nerve Blocks in Dermatologic Surgery

Recommendation	Strength of Recommendation	Level of Evidence	References
Nerve block anesthesia for ablative laser resurfacing of the face, botulinum toxin injection of the palm, and upper lid ptosis surgery	B	II	Lee, Khandwala, & Jones, 2009; Hund et al., 2004; Vadoud-Seyedi, Heenen, & Simonart, 2001; Wan et al., 2013
Nerve block as an alternate to local infiltration anesthesia for dermatologic surgery on the face and digits	C	III	Expert opinion

Recommendations for Tumescent Local Anesthesia in Dermatologic Surgery

• Lidocaine and prilocaine are both safe and recommended for use in tumescent local anesthesia for office-based liposuction. Bupivacaine is not recommended for this use.
• Use of prilocaine is not approved in the United States for this procedure as of the date of this publication.
• The addition of epinephrine to lidocaine is recommended and safe for use in tumescent local anesthesia for liposuction.
• A maximum dose of 55 mg/kg of lidocaine with epinephrine has been shown to be safe and can be used for tumescent local anesthesia for liposuction in patients weighing 43.6-81.8 kg.
• The use of warm anesthetic solution and a slow infiltration rate is recommended to decrease patient discomfort during administration of tumescent local anesthesia.

Strength of Recommendations for Tumescent Local Anesthesia in Dermatologic Surgery

Recommendation	Strength of Recommendation	Level of Evidence	References
Lidocaine and prilocaine for use in tumescent local anesthesia for office-based liposuction	A	I, II	Klein, 1990; Burk, Guzman-Stein, & Vasconez, 1996; Glowacka et al., 2009; Habbema, 2010; Lillis, 1988; Rubin et al., 1999; Augustin et al., 2010; Breuninger & Wehner-Caroli, 1998; Lindenblatt et al., 2004
The addition of epinephrine to lidocaine for use in tumescent local anesthesia for liposuction	A	I, II	Klein, 1990; Burk, Guzman-Stein, & Vasconez, 1996; Glowacka et al., 2009; Habbema, 2010; Lillis, 1988; Rubin et al., 1999
A maximum dose of 55 mg/kg of lidocaine with epinephrine for local tumescent anesthesia for liposuction	A	I	Ostad, Kageyama, & Moy, 1996
Use of a warm solution to decrease patient discomfort during administration of tumescent local anesthesia	B	II	Kaplan & Moy, 1996
Use of a slow infiltration rate to decrease patient discomfort during administration of tumescent local anesthesia	C	III	Hanke, et al., 1997

Definitions

Level of Evidence

1. Good-quality patient-oriented evidence (i.e., evidence measuring outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life).
2. Limited-quality patient-oriented evidence (i.e., lower quality clinical trials, cohort studies, and case control studies)
3. Other evidence, including consensus guidelines, opinion, case studies, or disease-oriented evidence (i.e., evidence measuring intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes)

Grade of Recommendation

1. Recommendation based on consistent and good-quality patient-oriented evidence.
2. Recommendation based on inconsistent or limited-quality patient-oriented evidence.
3. Recommendation based on consensus, opinion, case studies, or disease-oriented evidence.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

A variety of skin conditions requiring surgical intervention using local anesthesia provided in an office or facility outside of ambulatory surgical centers and hospital settings

Note: Anesthetic toxicity is rare in the dermatologic office setting, and therefore management of local anesthetic toxicity is not addressed in this guideline.

Guideline Category

Management

Treatment

Clinical Specialty

Anesthesiology

Dermatology

Intended Users

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Guideline Objective(s)

• To address the clinical use and safety of local anesthetics (i.e., topical, infiltrative, nerve blocks, and infiltrative tumescent) commonly used in office-based dermatologic surgery for adult and pediatric patients
• To facilitate the selection of the most effective means of achieving local anesthesia for a variety of cutaneous procedures while also minimizing the risk of adverse events

Target Population

Children and adults, including pregnant women, undergoing surgical procedures requiring anesthesia in office-based settings

Interventions and Practices Considered

1. Topical anesthesia
2. Local infiltrative anesthesia
   • Additives to local infiltrative anesthesia (epinephrine, hyaluronidase, buffering)
   • Methods to minimize pain of administration of local infiltration anesthesia
3. Nerve blocks/regional anesthesia
4. Tumescent local anesthesia

Major Outcomes Considered

• Analgesic efficacy
• Pain intensity
• Need for additional anesthetics
• Duration of anesthesia
• Patient satisfaction
• Pregnancy outcomes
• Adverse effects

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)

Hand-searches of Published Literature (Secondary Sources)

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Evidence was obtained for the clinical questions determined by the work group (see the "Description of the Methods Used to Formulate the Recommendations" field) using a systematic search of PubMed and Google Scholar databases from January 1960 through June 2014. Searches were prospectively limited to publications in the English language. Medical Subject Headings (MeSH) terms and strings used in the literature search included dermatology, skin, office-based surgery, local anesthesia, infiltration, topical anesthesia, lidocaine, tetracaine, prilocaine, marcaine, bupivacaine, etidocaine, mepivacaine, procaine, ester, amide, structure, comparison, efficacy, safety, risk, nerve blocks, tissue, face, head, neck, nose, ear, eye, lid, hands, feet, digits, penis, genitals, pregnancy, pediatrics, pain, tissue absorption, dose, time, slow, fast, volume, pharmacokinetics, serum levels, technique, method, laser, ethyl chloride, symptoms, systemic, toxicity, local anesthetic systemic toxicity (LAST), treatment, prevention, epinephrine, adrenaline, vasoconstriction, hyaluronidase, mixtures, solution, needle, cannula, sodium bicarbonate, pH, infusion rate, and tumescent anesthesia.

Exclusion and Inclusion Criteria for Study Selection

Inclusion Criteria

Type of Study

• Control of exposure: interventional, observational
• Timing: prospective, retrospective
• Design: evidence-based clinical guidelines; systematic reviews and meta-analyses; randomized controlled trials; non-randomized clinical trials; cross-sectional studies and cohort studies; case control studies; case reports

Outcomes

• Preference for outcomes that matter to patients and help them live longer or better lives (reduced mortality, symptom improvement, improved quality of life, increased safety, etc.)
• Depending on the clinical question, disease-oriented evidence outcomes were also considered (measurement of intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (e.g., blood loss, chemistry, anesthetic plasma levels, physiologic function, etc.).

Language

Studies only in English

Publication

Full-text available

Exclusion Criteria

• Type of study: animal studies, in-vitro research, letters
• Outcomes: No patient-oriented outcomes measured
• Language: Non-English studies
• Publication: Only abstract or no abstract

A total of 599 abstracts were initially assessed for possible inclusion. After removal of duplicate data and nonrelevant studies, 165 abstracts were retained and used for a secondary, manual search identifying 36 additional relevant studies.

Number of Source Documents

A total of 201 studies were included.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Evidence was graded using a 3-point scale based on the quality of methodology as follows:

1. Good-quality patient-oriented evidence (i.e., evidence measuring outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life)
2. Limited-quality patient-oriented evidence (i.e., lower quality clinical trials, cohort studies, and case control studies)
3. Other evidence, including consensus guidelines, opinion, case studies, or disease-oriented evidence (i.e., evidence measuring intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes)

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Once the full data set of 201 studies was collated, each study was reviewed and ranked based on relevance and the level of evidence for the outlined clinical questions. Evidence tables were generated for included studies and used by the work group in developing recommendations.

The available evidence was evaluated using a unified system called the Strength of Recommendation Taxonomy (SORT) that was developed by editors of the United States family medicine and primary care journals (i.e., American Family Physician, Family Medicine, Journal of Family Practice, and BMJ USA). Evidence was graded using a 3-point scale based on the quality of methodology (e.g., randomized control trial, case control, prospective or retrospective cohorts, case series, etc.) and the overall focus of the study (i.e., diagnosis, treatment, prevention, screening, or prognosis). (See the "Rating Scheme for the Strength of the Evidence" field.)

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

A work group composed of 8 dermatology experts practicing in office settings and in academic institutions, 1 anesthesiologist, and 1 patient advocate was convened to determine the scope of the guideline, and to identify important clinical questions in the use and safety of local anesthesia in office settings.

Clinical questions used to structure the evidence review for the use of local anesthesia in the office-based setting:

Topical Anesthesia

• Is topical anesthesia safer/more effective than other types of anesthesia to reduce pain?
• Are the same topical anesthetics used in adults also recommended/safe in pregnancy and lactation?
• Are the same topical anesthetics used in adults also recommended/safe in children?

Local Infiltration Anesthesia

• Is local infiltration anesthesia safer/more effective than other types of anesthesia to reduce pain?
• Does the method to calculate the maximum anesthetic doses change when infiltrated anesthetics are delivered over an extended time period compared to a short time period?
• Do the local anesthetic serum levels change based on the method of delivery?
• Is there a measure of care better/safer than others in decreasing the symptoms of systemic toxicity?
• Does the addition of epinephrine to infiltrated anesthetics increase safety risks in cardiac and pregnant patients, or for use in the digits, nose, and penis, compared to infiltrated anesthetics alone?
• Is a lower concentration of epinephrine as effective as high concentrations added to infiltrated anesthetics to produce vasoconstriction?
• Do the maximum recommended doses and delivery methods both in adults and children differ by the addition of epinephrine?
• Does the addition of hyaluronidase increase the diffusion rate and effectiveness/safety of infiltrative anesthetics?
• Does mixing multiple anesthetics pose a benefit to the patient compared to a single anesthetic for the same procedure?
• Does the addition of sodium bicarbonate to anesthetics decrease patients' pain when administered by subcutaneous infiltration?
• Does the use of a particular injection represent a clinical benefit for the patient?
• Does the use of other commonly used techniques minimize pain?

Nerve Block/Regional Anesthesia

• Does nerve block/regional anesthesia represent a clinical benefit over local infiltrative anesthesia for the head and neck, hands, feet, and genitals?
• Does the injection of local anesthesia in the optimal entry points for the head and neck, hands, feet, and genitals pose an increased risk of nerve damage from needle trauma and of toxicity?

Tumescent Anesthesia

• Is the use of lidocaine in tumescent anesthesia safer than other anesthetics for the same procedure?
• Does the volume and dose of lidocaine and epinephrine correlate with patient safety in tumescent anesthesia?
• Does a slow infusion rate result in less pain or a better anesthetic effect than fast infusion rates?
• Is there a measure of care better/safer than others to decrease symptoms of local anesthetic systemic toxicity for patients anesthetized using the tumescent technique?

Clinical recommendations were developed based on the best available evidence tabled in the guideline. In situations where documented evidence-based data were not available, or showing inconsistent or limited conclusions, expert opinion and medical consensus were used to generate clinical recommendations.

Rating Scheme for the Strength of the Recommendations

Clinical recommendations were developed based on the best available evidence. These are ranked as follows:

1. Recommendation based on consistent and good-quality patient-oriented evidence.
2. Recommendation based on inconsistent or limited-quality patient-oriented evidence.
3. Recommendation based on consensus, opinion, case studies, or disease-oriented evidence.

Cost Analysis

A systematic review of 22 trials encompassing >3000 patients was conducted to identify noncocaine anesthetics that were potentially less costly yet equally effective as those that contain cocaine. The review found no significant difference in efficacy among topical tetracaine-epinephrine-cocaine and 6 different cocaine-free formulations, but the addition of cocaine was associated with a higher cost and potential for adverse effects. Although no firm recommendation supporting the use of any single noncocaine formulation over another can be made, it is the opinion of this work group that because of the increased cost and potential for adverse events, noncocaine anesthetics are preferred over those containing cocaine for use in office-based dermatologic surgery.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

This guideline has been developed in accordance with the American Academy of Dermatology (AAD)/AAD Association Administrative Regulations for Evidence-based Clinical Practice Guidelines(version approved May 2012), which includes the opportunity for review and comment by the entire AAD membership and final review and approval by the AAD Board of Directors.

Evidence Supporting the Recommendations

References Supporting the Recommendations

Alam M, Ricci D, Havey J, Rademaker A, Witherspoon J, West DP. Safety of peak serum lidocaine concentration after Mohs micrographic surgery: a prospective cohort study. J Am Acad Dermatol. 2010 Jul;63(1):87-92. PubMed

Al-Qarqaz F, Al-Aboosi M, Al-shiyab D, Al Dabbagh Z. Using cold air for reducing needle-injection pain. Int J Dermatol. 2012 Jul;51(7):848-52. PubMed

Altinyazar HC, Ozdemir H, Koca R, Hosnuter M, Demirel CB, Gündogdu S. Epinephrine in digital block: color Doppler flow imaging. Dermatol Surg. 2004 Apr;30(4 Pt 1):508-11. PubMed

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

Augustin M, Maier K, Sommer B, Sattler G, Herberger K. Double-blind, randomized, intraindividual comparison study of the efficacy of prilocaine and lidocaine in tumescent local anesthesia. Dermatology (Basel). 2010;221(3):248-52. PubMed

Bartfield JM, Jandreau SW, Raccio-Robak N. Randomized trial of diphenhydramine versus benzyl alcohol with epinephrine as an alternative to lidocaine local anesthesia. Ann Emerg Med. 1998 Dec;32(6):650-4. PubMed

Bhole MV, Manson AL, Seneviratne SL, Misbah SA. IgE-mediated allergy to local anaesthetics: separating fact from perception: a UK perspective. Br J Anaesth. 2012 Jun;108(6):903-11. PubMed

Bonadio WA, Wagner V. Half-strength TAC topical anesthetic. For selected dermal lacerations. Clin Pediatr. 1988 Oct;27(10):495-8. PubMed

Breuninger H, Wehner-Caroli J. Slow infusion tumescent anesthesia. Dermatol Surg. 1998 Jul;24(7):759-63. PubMed

Bryan HA, Alster TS. The S-Caine peel: a novel topical anesthetic for cutaneous laser surgery. Dermatol Surg. 2002 Nov;28(11):999-1003; discussion 1003. PubMed

Burk RW 3rd, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg. 1996 Jun;97(7):1379-84. PubMed

Burns CA, Ferris G, Feng C, Cooper JZ, Brown MD. Decreasing the pain of local anesthesia: a prospective, double-blind comparison of buffered, premixed 1% lidocaine with epinephrine versus 1% lidocaine freshly mixed with epinephrine. J Am Acad Dermatol. 2006 Jan;54(1):128-31. PubMed

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

Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010 Dec;126(6):2031-4. PubMed

Clark LE, Mellette JR. The use of hyaluronidase as an adjunct to surgical procedures. J Dermatol Surg Oncol. 1994 Dec;20(12):842-4. PubMed

Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg. 2001 Jul;108(1):114-24. PubMed

Denkler K. Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet. Plast Reconstr Surg. 2005 Mar;115(3):802-10. PubMed

Drake LA, Dinehart SM, Goltz RW, Graham GF, Hordinsky MK, Lewis CW, Pariser DM, Skouge JW, Turner ML, Webster SB. Guidelines of care for local and regional anesthesia in cutaneous surgery. Guidelines/Outcomes Committee: American Academy of Dermatology. J Am Acad Dermatol. 1995 Sep;33(3):504-9. PubMed

Dunlevy TM, O'Malley TP, Postma GN. Optimal concentration of epinephrine for vasoconstriction in neck surgery. Laryngoscope. 1996 Nov;106(11):1412-4. PubMed

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 Mar;17(2):106-16. PubMed

Fayers T, Morris DS, Dolman PJ. Vibration-assisted anesthesia in eyelid surgery. Ophthalmology. 2010 Jul;117(7):1453-7. PubMed

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 Jul;22(7):507-9. PubMed

Fosko SW, Gibney MD, Harrison B. Repetitive pinching of the skin during lidocaine infiltration reduces patient discomfort. J Am Acad Dermatol. 1998 Jul;39(1):74-8. PubMed

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 Aug;201(2):186.e1-5. PubMed

Gadsden J, Hadzic A, Gandhi K, Shariat A, Xu D, Maliakal T, Patel V. The effect of mixing 1.5% mepivacaine and 0.5% bupivacaine on duration of analgesia and latency of block onset in ultrasound-guided interscalene block. Anesth Analg. 2011 Feb;112(2):471-6. PubMed

Gessler EM, Hart AK, Dunlevy TM, Greinwald JH. Optimal concentration of epinephrine for vasoconstriction in ear surgery. Laryngoscope. 2001 Oct;111(10):1687-90. PubMed

Glowacka K, Orzechowska-Juzwenko K, Bieniek A, Wiela-Hojenska A, Hurkacz M. Optimization of lidocaine application in tumescent local anesthesia. Pharmacol Rep. 2009 Jul-Aug;61(4):641-53. PubMed

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 Sep;41(5):533-8. PubMed

Gormley DE. Cutaneous surgery and the pregnant patient. J Am Acad Dermatol. 1990 Aug;23(2 Pt 1):269-79. PubMed

Green SM, Rothrock SG, Gorchynski J. Validation of diphenhydramine as a dermal local anesthetic. Ann Emerg Med. 1994 Jun;23(6):1284-9. PubMed

Gupta AK, Sibbald RG. Eutectic lidocaine/prilocaine 5% cream and patch may provide satisfactory analgesia for excisional biopsy or curettage with electrosurgery of cutaneous lesions. A randomized, controlled, parallel group study. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):419-23. PubMed

Habbema L. Efficacy of tumescent local anesthesia with variable lidocaine concentration in 3430 consecutive cases of liposuction. J Am Acad Dermatol. 2010 Jun;62(6):988-94. PubMed

Häfner HM, Röcken M, Breuninger H. Epinephrine-supplemented local anesthetics for ear and nose surgery: clinical use without complications in more than 10,000 surgical procedures. J Dtsch Dermatol Ges. 2005 Mar;3(3):195-9. PubMed

Häfner HM, Schmid U, Moehrle M, Strölin A, Breuninger H. Changes in acral blood flux under local application of ropivacaine and lidocaine with and without an adrenaline additive: a double-blind, randomized, placebo-controlled study. Clin Hemorheol Microcirc. 2008;38(4):279-88. PubMed

Hallen A, Ljunghall K, Wallin J. Topical anaesthesia with local anaesthetic (lidocaine and prilocaine, EMLA) cream for cautery of genital warts. Genitourin Med. 1987 Oct;63(5):316-9. PubMed

Hammes S, Raulin C. Evaluation of different temperatures in cold air cooling with pulsed-dye laser treatment of facial telangiectasia. Lasers Surg Med. 2005 Feb;36(2):136-40. PubMed

Hancox JG, Venkat AP, Hill A, Graham GF, Williford PM, Coldiron B, Feldman SR, Balkrishnan R. Why are there differences in the perceived safety of office-based surgery?. Dermatol Surg. 2004 Nov;30(11):1377-9. PubMed

Hanke CW, Coleman WP, Lillis PJ, Narins RS, Buening JA, Rosemark J, Guillotte R, Lusk K, Jacobs R, Coleman WP. Infusion rates and levels of premedication in tumescent liposuction. Dermatol Surg. 1997 Dec;23(12):1131-4. PubMed

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 Jan;19(1):63-7. PubMed

Hund M, Rickert S, Kinkelin I, Naumann M, Hamm H. Does wrist nerve block influence the result of botulinum toxin A treatment in palmar hyperhidrosis?. J Am Acad Dermatol. 2004 Jan;50(1):61-2. PubMed

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

Kaplan B, Moy RL. Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction. A randomized double-blind study. Dermatol Surg. 1996 Aug;22(8):707-9. PubMed

Kilmer SL, Chotzen V, Zelickson BD, McClaren M, Silva S, Calkin J, No D. Full-face laser resurfacing using a supplemented topical anesthesia protocol. Arch Dermatol. 2003 Oct;139(10):1279-83. PubMed

Kirby B, Butt A, Morrison AM, Beck MH. Type I allergic reaction to hyaluronidase during ophthalmic surgery. Contact Dermatitis. 2001 Jan;44(1):52. PubMed

Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993 Nov;92(6):1085-98; discussion 1099-100. PubMed

Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990 Mar;16(3):248-63. PubMed

Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004 Nov;51(5):755-9. PubMed

Lai F, Sutton B, Nicholson G. Comparison of L-bupivacaine 0.75% and lidocaine 2% with bupivacaine 0.75% and lidocaine 2% for peribulbar anaesthesia. Br J Anaesth. 2003 Apr;90(4):512-4. PubMed

Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005 Sep;30(5):1061-7. PubMed

Landsman L, Mandy SH. Adjuncts to scalp reduction surgery. Intraoperative tissue expanders and hyaluronidase. J Dermatol Surg Oncol. 1991 Aug;17(8):670-2. PubMed

Lee EJ, Khandwala M, Jones CA. A randomised controlled trial to compare patient satisfaction with two different types of local anaesthesia in ptosis surgery. Orbit. 2009;28(6):388-91. PubMed

Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol. 1988 Oct;14(10):1145-8. PubMed

Lindenblatt N, Belusa L, Tiefenbach B, Schareck W, Olbrisch RR. Prilocaine plasma levels and methemoglobinemia in patients undergoing tumescent liposuction involving less than 2,000 ml. Aesthetic Plast Surg. 2004 Nov-Dec;28(6):435-40. PubMed

Liu S, Carpenter RL, Chiu AA, McGill TJ, Mantell SA. Epinephrine prolongs duration of subcutaneous infiltration of local anesthesia in a dose-related manner. Correlation with magnitude of vasoconstriction. Reg Anesth. 1995 Sep-Oct;20(5):378-84. PubMed

Masters JE. Randomised control trial of pH buffered lignocaine with adrenaline in outpatient operations. Br J Plast Surg. 1998 Jul;51(5):385-7. PubMed

Mercado P, Weinberg GL. Local anesthetic systemic toxicity: prevention and treatment. Anesthesiol Clin. 2011 Jun;29(2):233-42. PubMed

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

Neal JM, Bernards CM, Butterworth JF, Di Gregorio G, Drasner K, Hejtmanek MR, Mulroy MF, Rosenquist RW, Weinberg GL. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010 Mar-Apr;35(2):152-61. PubMed

Neal JM, Mulroy MF, Weinberg GL, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. PubMed

Nicholson G, Sutton B, Hall GM. Comparison of 1% ropivacaine with 0.75% bupivacaine and 2% lidocaine for peribulbar anaesthesia. Br J Anaesth. 2000 Jan;84(1):89-91. PubMed

Niwa H, Sugimura M, Satoh Y, Tanimoto A. Cardiovascular response to epinephrine-containing local anesthesia in patients with cardiovascular disease. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Dec;92(6):610-6. PubMed

Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1996 Nov;22(11):921-7. PubMed

Ozdemir M, Ozdemir G, Zencirci B, Oksuz H. Articaine versus lidocaine plus bupivacaine for peribulbar anaesthesia in cataract surgery. Br J Anaesth. 2004 Feb;92(2):231-4. PubMed

Pierluisi GJ, Terndrup TE. Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations. Pediatr Emerg Care. 1989 Dec;5(4):211-5. PubMed

Priestley S, Kelly AM, 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 Jul;42(1):34-40. PubMed

Radovic P, Smith RG, Shumway D. Revisiting epinephrine in foot surgery. J Am Podiatr Med Assoc. 2003 Mar-Apr;93(2):157-60. PubMed

Raulin C, Greve B, Hammes S. Cold air in laser therapy: first experiences with a new cooling system. Lasers Surg Med. 2000;27(5):404-10. PubMed

Ribotsky BM, Berkowitz KD, Montague JR. Local anesthetics. Is there an advantage to mixing solutions?. J Am Podiatr Med Assoc. 1996 Oct;86(10):487-91. PubMed

Richards KA, Stasko T. Dermatologic surgery and the pregnant patient. Dermatol Surg. 2002 Mar;28(3):248-56. PubMed

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 Australas. 2007 Oct;19(5):427-32. PubMed

Rubin JP, Bierman C, Rosow CE, Arthur GR, Chang Y, Courtiss EH, May JW. The tumescent technique: the effect of high tissue pressure and dilute epinephrine on absorption of lidocaine. Plast Reconstr Surg. 1999 Mar;103(3):990-6; discussion 997-1002. PubMed

Russell GN, Desmond MJ, Fox MA. Local anesthesia for radial artery cannulation: a comparison of a lidocaine-prilocaine emulsion and lidocaine infiltration. J Cardiothorac Anesth. 1988 Jun;2(3):309-12. PubMed

Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med. 1998 Jan;31(1):36-40. PubMed

Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. Clinical results for use of local anesthesia with epinephrine in penile nerve block. J Deutschen Dermatologischen Gesellschaft. 2014 Apr;12(4):332-9. PubMed

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

Seow LT, Lips FJ, Cousins MJ, Mather LE. Lidocaine and bupivacaine mixtures for epidural blockade. Anesthesiology. 1982 Mar;56(3):177-83. PubMed

Serrera Figallo MA, Velázquez Cayón RT, Torres Lagares D, Corcuera Flores JR, Machuca Portillo G. Use of anesthetics associated to vasoconstrictors for dentistry in patients with cardiopathies. Review of the literature published in the last decade. J Clin Exp Dent. 2012 Apr;4(2):e107-11. PubMed

Sharma P, Czyz CN, Wulc AE. Investigating the efficacy of vibration anesthesia to reduce pain from cosmetic botulinum toxin injections. Aesthet Surg J. 2011 Nov;31(8):966-71. PubMed

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

Smith GA, Strausbaugh SD, Harbeck-Weber C, Shields BJ, Powers JD, Hackenberg D. Comparison of topical anesthetics without cocaine to tetracaine-adrenaline-cocaine and lidocaine infiltration during repair of lacerations: bupivacaine-norepinephrine is an effective new topical anesthetic agent. Pediatrics. 1996 Mar;97(3):301-7. PubMed

Smith SM, Barry RC. A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children. Pediatr Emerg Care. 1990 Dec;6(4):266-70. PubMed

Sonohata M, Nagamine S, Maeda K, Ogawa K, Ishii H, Tsunoda K, Asami A, Mawatari M. Subcutaneous single injection digital block with epinephrine. Anesthesiol Res Pract. 2012;2012:487650. PubMed

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

Stewart JH, Chinn SE, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia--II. J Dermatol Surg Oncol. 1990 Sep;16(9):842-5. PubMed

Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol. 1989 Oct;15(10):1081-3. PubMed

Sweet PT, Magee DA, Holland AJ. Duration of intradermal anaesthesia with mixtures of bupivacaine and lidocaine. Can Anaesth Soc J. 1982 Sep;29(5):481-3. PubMed

Swinehart JM. The ice-saline-Xylocaine technique. A simple method for minimizing pain in obtaining local anesthesia. J Dermatol Surg Oncol. 1992 Jan;18(1):28-30. PubMed

Vadoud-Seyedi J, Heenen M, Simonart T. Treatment of idiopathic palmar hyperhidrosis with botulinum toxin. Report of 23 cases and review of the literature. Dermatology. 2001;203(4):318-21. [17 references] PubMed

van den Berg AA, Montoya-Pelaez LF. Comparison of lignocaine 2% with adrenaline, bupivacaine 0.5% with or without hyaluronidase and a mixture of bupivacaine, lignocaine and hyaluronidase for peribulbar block analgesia. Acta Anaesthesiol Scand. 2001 Sep;45(8):961-6. PubMed

Wan K, Jing Q, Sun QN, Wang HW, Zhao JZ, Ma L, Kong LJ. Application of a peripheral nerve block technique in laser treatment of the entire facial skin and evaluation of its analgesic effect. Eur J Dermatol. 2013 May-Jun;23(3):324-30. PubMed

Welch MN, Czyz CN, Kalwerisky K, Holck DE, Mihora LD. Double-blind, bilateral pain comparison with simultaneous injection of 2% lidocaine versus buffered 2% lidocaine for periocular anesthesia. Ophthalmology. 2012 Oct;119(10):2048-52. PubMed

White JM, Siegfried E, Boulden M, Padda G. Possible hazards of cryogen use with pulsed dye laser. A case report and summary. Dermatol Surg. 1999 Mar;25(3):250-2; discussion 252-3. PubMed

Wilhelmi BJ, Blackwell SJ, Miller JH, Mancoll JS, Dardano T, Tran A, Phillips LG. Do not use epinephrine in digital blocks: myth or truth?. Plast Reconstr Surg. 2001 Feb;107(2):393-7. PubMed

Xia Y, Chen E, Tibbits DL, Reilley TE, McSweeney TD. Comparison of effects of lidocaine hydrochloride, buffered lidocaine, diphenhydramine, and normal saline after intradermal injection. J Clin Anesth. 2002 Aug;14(5):339-43. PubMed

Yoon WY, Chung SP, Lee HS, Park YS. Analgesic pretreatment for antibiotic skin test: vapocoolant spray vs ice cube. Am J Emerg Med. 2008 Jan;26(1):59-61. PubMed

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

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of local anesthesia in office-based dermatologic surgery

Potential Harms

• Many topical anesthetic agents are effective and safe for use in dermatologic procedures with a low risk of adverse events. However, caution must be taken when occlusion is used or large surface areas are treated because there are no data supporting standard practice. This is particularly true with compounded mixtures and nonstandard doses, which although rarely used by dermatologists may increase the risk of adverse events and even death.
• The risk of toxicity of topical anesthetics in children, although rare, is increased by differences in children's body surface area (BSA) relative to weight and by a lack of linear relationship between BSA and drug exposure or response. Potential adverse effects include methemoglobinemia with application of eutectic mixtures of lidocaine and prilocaine (equal mixtures of the 2 solid compounds by weight, which forms an oil above 18° C), and symptoms of local anesthetic systemic toxicity (LAST), which may occur from any topical anesthetic. The recommendations for use provided in the package insert for each specific medication should be followed to avoid these complications.
• Allergy to lidocaine is rare, with a genuine immunologic reaction representing only 1% of all adverse reactions to topical anesthetic medications.
• Although there is great interpatient variability in the manifestations of LAST, the signs and symptoms tend to follow a progression of central nervous system excitement. The patient may initially experience circumoral numbness, facial tingling, pressured or slurred speech, metallic taste, auditory changes, and hallucinations, which may also be accompanied by hypertension and tachycardia. As the condition evolves, seizures or central nervous system depression may develop, and severe cases may end in cardiac failure or arrest.
• The pain of administering infiltration anesthesia, coupled with the anxiety surrounding the injection, can often lead to significant discomfort for a child.
• Epinephrine is rated as a pregnancy category C drug by the U.S. Food and Drug Administration, but in small amounts appears safe for use with local infiltrative anesthesia in pregnant women. One study suggested an increase in malformations when mothers were exposed to systemic epinephrine in the first trimester. The alfa-adrenergic properties of epinephrine may cause vasoconstriction of placental blood vessels. When used in small amounts for dermatologic surgery, however, the local vasoconstriction afforded by epinephrine limits maternal blood level and placental transfer of lidocaine, and the benefits seem to outweigh the risks. Despite this, clinicians should postpone nonemergent dermatologic surgery requiring local infiltration anesthesia until after delivery to avoid undue risk. If possible, urgent surgery should be delayed until at least the second trimester. In cases where large amounts of anesthesia are necessary, consultation with the patient’s obstetrician may be helpful to assess the risk to benefit ratio of the procedure.
• If considering ethyl chloride for analgesia before the use of energy-based devices, caution should be used because it is flammable. There is 1 reported case of unwanted ignition with laser therapy that caused a first-degree burn.
• Research for use of nerve blocks in dermatologic procedures has found the technique to be safe when performed in this setting. Neither nerve damage nor other major adverse events have been reported, and mild events were limited to hematoma formation and 1 case of pain at the site of ulnar nerve block, all of which were transient.
• Multiple studies estimate the rate of serious adverse events associated with tumescent local anesthesia to be 0.04% to 0.16%.

Contraindications

Contraindications

• There are no data available on the safety of topical anesthesia agents other than lidocaine, and their use during pregnancy and lactation is not recommended.
• Hyaluronidase should not be administered to patients with a known bee venom allergy.

Qualifying Statements

Qualifying Statements

Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be interpreted as setting a standard of care, or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the disease. This guideline reflects the best available data at the time the guideline was prepared. The results of future studies may require revisions to the recommendations in this guideline to reflect new data.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Safety

Identifying Information and Availability

Bibliographic Source(s)

Kouba DJ, LoPiccolo MC, Alam M, Bordeaux JS, Cohen B, Hanke CW, Jellinek N, Maibach HI, Tanner JW, Vashi N, Gross KG, Adamson T, Begolka WS, Moyano JV. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol. 2016 Jun;74(6):1201-19. [141 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2016 Jun

Guideline Developer(s)

American Academy of Dermatology - Medical Specialty Society

Source(s) of Funding

Funding sources: None

Funding of guideline production by medical or pharmaceutical entities is prohibited.

Guideline Committee

Office-based Surgery Work Group

Composition of Group That Authored the Guideline

Work Group Members: David J. Kouba, MD, PhD (Chair); Matteo C. LoPiccolo, MD; Murad Alam, MD; Jeremy S. Bordeaux, MD, MPH; Bernard Cohen, MD; C. William Hanke, MD; Nathaniel Jellinek, MD; Howard I. Maibach, MD; Jonathan W. Tanner, MD, PhD; Neelam Vashi, MD; Kenneth G. Gross, MD; Trudy Adamson, MSN, RN, DNC; Wendy Smith Begolka, MBS; Jose V. Moyano, PhD

Financial Disclosures/Conflicts of Interest

The American Academy of Dermatology (AAD) strives to produce clinical guidelines that reflect the best available evidence supplemented with the judgment of expert clinicians. Significant efforts are taken to minimize the potential for conflicts of interest to influence guideline content. The management of conflict of interest for this guideline complies with the Council of Medical Specialty Societies’ Code of Interactions with Companies. Funding of guideline production by medical or pharmaceutical entities is prohibited, full disclosure is obtained and evaluated for all guideline contributors throughout the guideline development process, and recusal is used to manage identified relationships. The AAD conflict of interest policy summary may be viewed at www.aad.org .

Work group members completed a disclosure of interests, which was periodically updated and reviewed throughout guideline development. If a potential conflict was noted, the work group member recused him or herself from discussion and drafting of recommendations pertinent to the topic area of the disclosed interest.

The below information represents the authors disclosed relationships with industry. Relevant relationships requiring recusal for drafting of guideline recommendations and content were not noted for this guideline.

Murad Alam, MD, served as consultant for Amway Corporation, receiving honoraria, and as Principal Investigator (PI) for OptMed, receiving grants with no personal compensation received.

Bernard Cohen, MD, served on the Advisory Board of Sanofi-Aventis, receiving honoraria.

C. William Hanke, MD, received honoraria serving on the Advisory Board of Allergan, Inc, as consultant for Orlando Dermatology Aesthetic & Clinical, as speaker for LEO Pharma and Genentech, Inc, and in other roles for Educational Testing and Assessment Systems, Inc and for SanovaWorks. In addition, Dr Hanke served as PI in grants funded by Allergan, Inc, Derm Advance, Genentech, Inc, and LEO Pharma, and received compensation for patent royalties or other compensation for intellectual property rights from Elsevier, Informa HealthCare, and Springer Science & Business Media.

Neelam Vashi, MD, served as a consultant to L'Oreal, receiving honoraria.

Trudy Adamson, Jeremy Burdeaux, MD, MPH, Nathaniel Jellinek, MD, David Kouba, MD, PhD, Matteo LoPiccolo, MD, Howard Maibach, MD, Jose Moyano, PhD, and Wendy Smith Begolka, MBS have no relevant conflicts of interest to disclose.

Guideline Status

This is the current release of the guideline.

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Available from the Journal of the American Academy of Dermatology Web site .

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 15, 2016. The information was verified by the guideline developer on October 17, 2016.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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