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Local Anesthetics in Cosmetic Dermatology

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Local Anesthetics in Cosmetic Dermatology COSMETIC DERMATOLOGY Local Anesthetics in Cosmetic Dermatology Peter W. Hashim, MD, MHS; John K. Nia, MD; Mark Taliercio, BS; Gary Goldenberg, MD PRACTICE POINTS • The proper delivery of local anesthesia is integral to successful cosmetic interventions. • Regional nerve blocks can provide effective analgesia while reducing the number of injections and preserving the architecture of the cosmetic field. copy Local anesthetics play an important role in cos- LOCAL ANESTHETICS metic dermatology. Techniques using topical and The sensation of pain is carried to the central ner- regional anesthesia provide numerous pain man- vousnot system by unmyelinated C nerve fibers. Local agement options for laser and injection treatments. anesthetics (LAs) act by blocking fast voltage-gated In this article, we review strategies to maximize sodium channels in the cell membrane of the nerve, patient comfort during cosmetic interventions. thereby inhibiting downstream propagation of an Cutis. 2017;99:393-397.Doaction potential and the transmission of painful stimuli.1 The chemical structure of LAs is funda- mental to their mechanism of action and metabo- ocal anesthesia is a central component of suc- lism. Local anesthetics contain a lipophilic aromatic cessful interventions in cosmetic dermatol- group, an intermediate chain, and a hydrophilic Logy. The number of anesthetic medications amine group. Broadly, agents are classified as amides and administration techniques has grown in recent or esters depending on the chemical group attached years as outpatient cosmetic procedures continue to the intermediate chain.2 Amides (eg, lidocaine, to expand. Pain is a commonCUTIS barrier to cosmetic bupivacaine, articaine, mepivacaine, prilocaine, procedures, and alleviating the fear of painful inter- levobupivacaine) are metabolized by the hepatic sys- ventions is critical to patient satisfaction and future tem; esters (eg, procaine, proparacaine, benzocaine, visits. To accommodate a multitude of cosmetic chlorprocaine, tetracaine, cocaine) are metabolized interventions, it is important for clinicians to be well by plasma cholinesterase, which produces para- versed in applications of topical and regional anes- aminobenzoic acid, a potentially dangerous metabo- thesia. In this article, we review pain management lite that has been implicated in allergic reactions.3 strategies for use in cosmetic practice. Lidocaine is the most prevalent LA used in der- matology practices. Importantly, lidocaine is a class IB antiarrhythmic agent used in cardiology to treat ven- tricular arrhythmias.4 As an anesthetic, a maximum dose of 4.5 mg/kg can be administered, increasing From the Department of Dermatology, Icahn School of Medicine at to 7.0 mg/kg when mixed with epinephrine; with Mount Sinai, New York, New York. higher doses, there is a risk for central nervous sys- The authors report no conflict of interest. tem and cardiovascular toxicity.5 Initial symptoms Correspondence: Gary Goldenberg, MD, Department of Dermatology, Icahn School of Medicine at Mount Sinai Medical of lidocaine toxicity include dizziness, tinnitus, cir- Center, 5 E 98th St, New York, NY 10029 cumoral paresthesia, blurred vision, and a metallic ([email protected]). taste in the mouth.6 Systemic absorption of topical WWW.CUTIS.COM VOLUME 99, JUNE 2017 393 Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Cosmetic Dermatology anesthetics is heightened across mucosal membranes, with a 1064-nm Nd:YAG laser, no significant dif- and care should be taken when applying over large ferences were found.15 The maximum application surface areas. area is 100 cm2 in children weighing less than Allergic reactions to LAs may be local or less 20 kg. A study of healthy adults demonstrated safety frequently systemic. It is important to note that with the use of 30 to 60 g of occluded liposomal LAs tend to show cross-reactivity within their class lidocaine cream 4%.16 rather than across different classes.7 Reactions can be In addition to US Food and Drug Administration– classified as type I or type IV. Type I (IgE-mediated) approved products, several compounded pharmacy reactions evolve in minutes to hours, affecting the products are available for topical anesthesia. These skin and possibly leading to respiratory and cir- formulations include benzocaine-lidocaine-tetracaine culatory collapse. Delayed reactions to LAs have gel, tetracaine-adrenaline-cocaine solution, and increased in recent years, with type IV contact lidocaine-epinephrine-tetracaine solution. A triple- allergy most frequently found in connection with anesthetic gel, benzocaine-lidocaine-tetracaine is benzocaine and lidocaine.8 widely used in cosmetic practice. The product has been shown to provide adequate anesthesia for laser TOPICAL ANESTHESIA resurfacing after 20 minutes without occlusion.17 Topical anesthetics are effective and easy to use Of note, compounded anesthetics lack standardiza- and are particularly valuable in patients with needle tion, and different pharmacies may follow their own phobia. In certain cases, these medications may individual protocols. be applied by the patient prior to arrival, thereby reducing visit time. Topical agents act on nerve REGIONAL ANESTHESIA fibers running through the dermis; therefore, effi- Regional nervecopy blockade is a useful option for more cacy is dependent on successful penetration through widespread or complex interventions. Using regional the stratum corneum and viable epidermis. To nerve blockade, effective analgesia can be delivered enhance absorption, agents may be applied under an to a target area while avoiding the toxicity and pain occlusive dressing. associatednot with numerous anesthetic infiltrations. In Topical anesthetics are most commonly used addition, there is no distortion of the tissue architec- for injectable fillers, ablative and nonablative ture, allowing for improved visual evaluation during laser resurfacing, laser hair removal, and tattoo the procedure. Recently, hyaluronic acid fillers have removal. The eutectic mixture of 2.5% lidocaineDo been compounded with lidocaine as a means of and 2.5% prilocaine as well as topical 4% or reducing procedural pain. 5% lidocaine are the most commonly used US Food and Drug Administration–approved products for Blocks for Dermal Fillers topical anesthesia. In addition, several compounded Forehead—For dermal filler injections of the glabel- pharmacy products are available. lar and frontalis lines, anesthesia of the forehead After 60 minutes of application of the eutectic may be desired. The supraorbital and supratrochlear mixture of 2.5% lidocaine and 2.5% prilocaine, nerves supply this area. The supraorbital nerve can a 3-mm depth of analgesiaCUTIS is reached, and after be injected at the supraorbital notch, which is mea- 120 minutes, a 4.5-mm depth is reached.9 It elicits sured roughly 2.7 cm from the glabella. The orbital a biphasic vascular response of vasoconstriction and rim should be palpated with the nondominant hand, blanching followed by vasodilation and erythema.10 and 1 to 2 mL of anesthetic should be injected just Most adverse events are mild and transient, but below the rim (Figure 1). The supratrochlear nerve allergic contact dermatitis and contact urticaria have is located roughly 1.7 cm from the midline and can been reported.11-13 In older children and adults, the be similarly injected under the orbital rim with 1 to maximum application area is 200 cm2, with a maxi- 2 mL of anesthetic (Figure 1). mum dose of 20 g used for no longer than 4 hours. Lateral Temple Region—Anesthesia of the The 4% or 5% lidocaine cream uses a liposo- zygomaticotemporal nerve can be used to reduce mal delivery system, which is designed to improve pain from dermal filler injections of the lateral cutaneous penetration and has been shown to pro- canthal and temporal areas. The nerve is identified vide longer durations of anesthesia than nonliposo- by first palpating the zygomaticofrontal suture. A mal lidocaine preparations.14 Application should be long needle is then inserted posteriorly, immediately performed 30 to 60 minutes prior to a procedure. behind the concave surface of the lateral orbital rim, In a study comparing the eutectic mixture of and 1 to 2 mL of anesthetic is injected (Figure 1). 2.5% lidocaine and 2.5% prilocaine versus lidocaine Malar Region—Blockade of the zygomaticofacial cream 5% for pain control during laser hair removal nerve is commonly performed in conjunction with 394 CUTIS® WWW.CUTIS.COM Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Cosmetic Dermatology the zygomaticotemporal nerve and provides anes- be anesthetized using 4 to 5 submucosal injections at thesia to the malar region for cheek augmentation evenly spaced intervals between the canine teeth.18 procedures. To identify the target area, the junc- tion of the lateral and inferior orbital rim should be Blocks for Palmoplantar Hyperhidrosis palpated. With the needle placed just lateral to this The treatment of palmoplantar hyperhidrosis ben- point, 1 to 2 mL of anesthetic is injected (Figure 1). efits from regional blocks. Botulinum toxin has been well established as an effective therapy for the condi- Blocks for Perioral Fillers tion.19-21 Given the sensitivity of palmoplantar sites, Upper Lips/Nasolabial Folds—Bilateral blockade of it is valuable to achieve
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