RESULTS Factors that should be considered to reduce the risk of side effects associated with the use of topical anesthetics include the amount of product used, body location, size of the surface area, and duration of product application. Many case reports document adverse outcomes associated with the use of compounded products that the Food and Drug Administration has not approved that have inappropriately high anesthetic concentrations and from the use of topical anesthetics on excessively large skin surface areas during laser treatments. CONCLUSIONS Lidocaine-containing products play an integral role in cutaneous anesthesia by providing patient comfort with minimal side effects. Careful attention must be paid to the particular anatomic location, the total surface area covered, and the duration of anesthetic skin contact. The authors have indicated no significant interest with commercial supporters.

Topical anesthetics for dermatologic procedures: a review.

Topical anesthetic creams have positive applications in plastic surgery. For certain procedures, they can replace injected local anesthetics. By replacing injections with a topical cream, the negative effects associated with injections, such as pain, needle anxiety, and edema at the surgical site, are eliminated. A variety of U.S. Food and Drug Administration-approved topical anesthetic creams are available for use; however, much care must be taken when prescribing and administering these drugs, as anesthetic creams compounded in nonstandard doses can result in severe toxicity and death. When used appropriately, topical anesthetic creams can provide a safe and effective alternative to other forms of anesthesia. This article provides an overview of topical anesthetic creams, including availability, composition, safety, and efficacy.

Topical anesthetic creams.

There are multiple different topical anesthetic options available to minimize the pain associated with cosmetic dermatologic procedures. These options, either alone or in combination, have diverse profiles for effectiveness, ease of use, application time, need for occlusion, and side effects. The lidocaine/tetracaine cream (Pliaglis®, Galderma Laboratories, Texas, USA), one of the newer combination options, offers effective pain alleviation that has been evaluated in numerous clinical trials. This combination anesthetic is associated with a very favorable profile because of its ease of use and mild side effects compared to other topical local anesthetics. An overview of available topical local anesthetics will be provided with an outline of clinical study characteristics and results regarding the use of lidocaine/tetracaine cream.

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Review of lidocaine/tetracaine cream as a topical anesthetic for dermatologic laser procedures.

Laser resurfacing technology offers the ability to treat skin changes that are the result of the aging process. One of the major drawbacks of laser resurfacing technologies is the pain associated with the procedure. The methods of anesthesia used in laser resurfacing to help minimize the pain include both noninvasive and invasive procedures. The noninvasive procedures can be divided into topical, cryoanesthesia, and a combination of both. The invasive methods of anesthesia include injected forms (infiltrative, nerve blocks, and tumescent anesthesia) and supervised anesthesia (monitored anesthesia care and general anesthesia). In this review, the authors summarize the types of anesthesia used in laser resurfacing to aid the provider in offering the most appropriate method for the patient to have as painless a procedure as possible.

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Anesthesia methods in laser resurfacing.

Summary
Background The ‘cosmeceutical’ agent 2-dimethylaminoethanol (DMAE) is a tertiary amine found in high concentration in numerous topical antiwrinkle preparations.

Objectives  We hypothesized that a 337 mmol L−1 (3%) DMAE reservoir applied to the skin could reproduce the cytopathology induced by other amines by maintaining a millimolar drug concentration within a certain depth of the skin layers, and that vacuolar cell expansion could account for the very rapid effect on the apparent skin fullness.

Methods  Morphological and functional assays were applied to cultured rabbit dermal fibroblasts treated with tertiary amines in vitro. A morphological verification of the vacuolization caused by topical DMAE was also attempted in vivo using the inner skin of the rabbit ear and in vitro using primary cultures of human cutaneous epithelial cells.

Results  Fibroblasts responded to DMAE (2·5–10 mmol L−1) by massive vacuolization (0·5–4 h; phase contrast observations). Triethanolamine, another chemical frequently used topically, was also active in this respect (10 mmol L−1). The vacuolar adenosine triphosphatase inhibitor bafilomycin A1 prevented DMAE- or triethanolamine-induced vacuolization; adding bafilomycin A1 or cell washout slowly reversed the established vacuolization induced by DMAE. Further effects of DMAE in cultured fibroblasts included a moderate cytotoxicity (10 mmol L−1) that was abated by bafilomycin A1 cotreatment, a concentration-dependent mitotic arrest (2·5 mmol L−1) and transient and mild effects on cell ploidy. The epidermis of the rabbit external ear was significantly thickened and exhibited clear perinuclear swelling indicative of vacuolization in response to 3% DMAE (1 h; paraffin tissue sections). Cultured human cutaneous epithelial cells responded to DMAE by vacuolization (inhibited by bafilomycin A1 cotreatment).

Conclusions  The vacuolar cytopathology induced by concentrated organic amines may be the cellular basis of the antiwrinkle effect of DMAE.

The antiwrinkle effect of topical concentrated 2‐dimethylaminoethanol involves a vacuolar cytopathology

Summary EMLA ® cream is used in plastic surgery as a topical anaesthetic to harvest split skin grafts. It has been observed that the skin appears pale and oedematous after the application of EMLA ® . The aim our study was to determine the effect of EMLA ® with an occlusive dressing on skin thickness using a high frequency ultrasound. Twenty volunteers took part in this study after approval from the ethics committee. An area of skin was marked on both thighs and the skin thickness of each, measured using ultrasound. EMLA ® with an occlusive dressing was applied to one thigh. This was removed after at least 2h of application time but at different time points and skin thickness of each thigh measured again. Data was analysed using t -test and Pearson's correlation. Mean age in years±SD (range) was 36.1±12.1 (23–61). Male:female ratio was 8:12. Mean skin thickness±SEM increased from 1.86±0.055mm prior to EMLA ® application to 1.96±0.051mm post-EMLA ® application p =0.02. There was a significant correlation between the increase in skin thickness and duration of application of EMLA ® cream ( p = R 2 =0.59). The results conclude that EMLA ® applied under an occlusive dressing has an effect on skin tissue thickness and any surgeon who harvests split skin grafts under EMLA ® should be aware of this. Further research is needed to compare laser treatments performed under local anaesthetic creams against general anaesthesia as an increase in skin thickness may affect the depth of laser penetration.

J.D. Nancarrow

Papers

The effect of local anaesthetic cream (EMLA) applied with an occlusive dressing on skin thickness. Does it matter

The ‘pull out’ tie-over dressing☆