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DMSO and Lidocaine

Topical Lidocaine for Anesthesia in Patients Undergoing Pulsed Dye Laser Treatment for Vascular MalformationsTopical
Lidocaine for Anesthesia in Patients Undergoing Pulsed Dye Laser Treatment
for Vascular Malformations
Susan B. Mallory, MDa, Paul A. Lehman, M.S., Douglas R. Vanderpool, MD,
Thomas J. Franz, MDb


Anesthetic patches of lidocaine in acid mantle cream have been used for
cutaneous anesthesia. 11 However, when we performed in vitro penetration
studies we found that only a small amount of lidocaine mixed in acid
mantle cream was absorbed percutaneously compared with that mixed in DMSO.
Similarly, although EMLA is a popular anesthetic for reducing superficial
pain,9 it delivered very little total anesthetic drug within two hours of
application.
Tetracaine base 33% in 100% DMSO was used to achieve dermal anesthesia. 12
Local anesthetic bases are readily soluble in DMSO compared with their
salts. Dimethyl sulfoxide has been used to increase penetration of
chemicals applied to the skin in percutaneous absorption studies, however,
these formulations have not received Food and Drug Administration approval
for commercial use. The major disadvantage of DMSO is the whealing
response, which is strongly influenced by body region and dose. 13 It was
necessary for us to outline the lesion with a ball-point pen prior to
applying the solution so that we could tell where the vascular lesion
stopped.
Various methods to increase percutaneous absorption of medicines have been
used. lontophoresis, the electrical enhancement of ionic transport,
increases penetration of topical agents but requires special equipment. 14
We were interested in finding an easy topical method of achieving
anesthesia without special equipment.
Side effects of topical anesthetics can include mild stinging and itching
at the site of application. We had no patients who complained of this.
Initial transient local redness was seen in all patients, but disappeared
by the time of laser treatment.
Major toxic effects of lidocaine involve the heart and central nervous
system (CNS). 15 Cardiac effects occur because of direct action causing
heart block in patients with preexisting bundle branch disease. The CNS
effects can occur when the serum lidocaine concentration is 5 mg/L or
greater. Dizziness, drowsiness, perioral paresthesias, and tinnitus may be
noted early. More toxic effects are delirium, disorientation, convulsions,
and coma. The amount of drug absorbed percutaneously in our preparation
using six drops or fewer was far below the toxic range. The maximum amount
of lidocaine that could be absorbed was 75 mg over 24 hours (based on the
time course of penetration shown in Figure 1), assuming that none of the
applied dose was rubbed or washed off during or after the clinic visit.
Our dose of topical lidocaine, even if totally absorbed, was far less than
what is recommended for maximum intralesional use, recommended at 4.5
mg/kg of body weight for children or adults. We saw no evidence of ECG
anomalies, cardiac, or CNS disturbances.
Measurement of pain or anesthesia is difficult to assess and is highly
subjective. Visual analog scales have a higher sensitivity in adults than
the traditional simple descriptive verbal scale. 16 We used both in our
study, mainly to confirm that patients understood the procedure and the
scale. Because many of our patients were young, we also wanted to verify
their understanding of the scale.


Summary


We found 25% lidocaine base mixed in 70% DMSO/ethanol to be an effective
and well-tolerated topical anesthetic that can be applied in the office
prior to treatment with the pulsed dye laser. This approach did not
produce total anesthesia, but was sufficient to allow the patient to
complete a treatment with minimum discomfort as opposed to having to come
back several times for therapy. The alternatives, general anesthesia and
conscious sedation, are not accepted by many patients. One word of caution
should be mentioned. As in the case of injectable lidocaine, limits as to
the total amount of topical lidocalne used should be established. Large
areas should not be freely painted with this mixture, nor should it be
used on infants without considering systemic absorption.
References
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; 16:1008-1011.
Franz TJ. The finite dose technique as a valid in vitromodel for the study
of percutaneous absorption in man. Curr Probl Dermatol 1978;7:58-68.
Franz TJ. Percutaneous absorption. On the relevance of in vitro data. J
Invest Dermatol 1975;64:190-195.
Franz TJ, Lehman PA. The use of water permeability as a means of
validation for skin integrity in in vitro percutaneous absorption studies.
J Invest Dermatol 1990,95:525.
Lubens HM, Sanker JF. Anesthetic skin patch. Ann Allergy 1964:22:37-41.
Lubens HM, Ausdenmoore RW. Shafer AD, Reece RM. Anesthetic patch for
painful procedures such as minor operations. Am J Dis Child
1974,128:192-194.
de Waard-van der Spek FB, Oranje AP, Lillieborg S, Hop WCJ, Stolz E.
Treatment of molluscum contagiosum using a lidocaine/prilocaine cream
(EMLA) for analgesia. J Am Acad Derrnatol 1990;23:685-688.
Tan OT, Gilchrest BA. Laser therapy for selected cutaneous vascular
lesions in the pediatric population: a review. Pediatrics 1988;82:652-662.
de Waard-van der Spek FB, van den Berg GM, Oranje AP. EMLA cream: an
improved local anesthetic. Review of current literature. Pediatr Dermatol
1992;9:126-131.
Halperin DL, Koren G, Attias D, Pellegrini E. Topical skin anesthesia for
venous, subcutaneous drug reservoir and lumbar punctures in children.
Pediatrics 1989;84:281-284.
Niamtu J, Campbell RL, Garrett MS. The anesthetic skin patch for topical
anesthesia. J Oral Maxillofac Surg 1984;42:839-840.
Prechner VL, Cohen DD, Pretsky I. Dermal anesthegia by the topical
application of tetracaine base dissolved in dimethyl sulfoxide. Ann NY
Acad Sci 1967;141:524-531.
Frosch PJ, Duncan S, Kligman AM. Cutaneous biometrics. I. The response of
human skin to dimethyl ulphoxide. Br J Dermatol 1980;102:263-273.
Russo J, Lipman AG. Comstock TJ, Page BC, Stephen RL. Lidocaine
anesthesia: comparison of iontophoresis, injection, and swabbing. Am J
Hosp Pharm 1980:37:843-837.
Lie RL, Vermeer BJ, Edelbroek PM. Severe lidocaine intoxication by
cutaneous absorption. J Am Acad Dermatol 1990;23:1026-1028.
Scott J, Huskisson EC. Graphic representation of pain. Pain
1976,2:175-184.
aDivision of Dermatology, Washington University School of Medicine, St.
Louis, Missouri.
bDepartment of Dermatology, University of Arkansas for Medical Sciences,
Little Rock, Arkansas.


Address correspondence to: Thomas J. Franz, MD, Department of Dermatology,
MS 576, University of Arkansas for Medical Sciences, 4301 W. Markham
Street, Little Rock, AR 72205- 7199. No reprints available.
Source
*This article appeared in Pediatric Dermatology, Volume 10, Number 4, pp.
370-375.
DMSO wishes to thank the publisher of Pediatric Dermatologyfor allowing
this article to be placed on our World Wide Web site. To copy any portion
of this article, please obtain permission from the publisher.



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