Topical Anesthetics

Topical Anesthetics

PEP Topic 
Acute Pain
Description 

The topical use of anesthetics consists of applying an anesthetic agent, such as lidocaine, to the skin or mucosa. In cancer care, topical anesthetics are used to reduce the acute pain of diagnostic procedures, such as biopsy, and postoperative incisions. Topical anesthetics have been examined in chronic pain as well.

 

Effectiveness Not Established

Research Evidence Summaries

Cheville, A.L., Sloan, J.A., Northfelt, D.W., Jillella, A.P., Wong, G.Y., Bearden III, J.D., . . . Loprinzi, C.L. (2009). Use of a lidocaine patch in the management of postsurgical neuropathic pain in patients with cancer: A phase III double-blind crossover study (N01CB). Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 17(4), 451–460.

doi: 10.1007/s00520-008-0542-x
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Study Purpose:

To investigate the efficacy of one or more lidocaine patches in reducing incisional pain

Intervention Characteristics/Basic Study Process:

In the initial four-week treatment phase, patients received either lidocaine patches or placebo to apply to postsurgical incisional sites. After four weeks, the lidocaine group received placebo and vice versa. Pain was rated at baseline and at four and eight weeks.

 

Sample Characteristics:

  • The sample was composed of 28 patients. 
  • Mean patient age was 61.9 years.
  • Nineteen patients (68%) were female. Nine patients (32%) were male.
  • Eligible patients
    • Had experienced pain for one month or longer, and the pain rating was equal to or greater than 4.
    • Had pain with neuropathic features (e.g., burning, paresthesias, allodynia), pain involving an area that could be covered by three patches or fewer, pain related to a surgical site associated with cancer treatment.
    • Were at least 18 years old and had no recent history of drug or alcohol abuse.
    • Were expected to live for a period longer than six months.
    • Had no evident cognitive or psychiatric morbidity.
    • Were neither pregnant nor nursing.
  • Patients were ineligible if their condition involved nonsurgical pain etiologies (e.g., malignancy, dermal pathology,  chemotherapy-induced neuropathy) at the painful site.

Setting:

  • Multisite
  • Ten clinical centers
  • United States

Study Design:

Double-blind, randomized, two-period crossover trial

Measurement Instruments/Methods:

  • Rating of pain intensity
  • Brief Pain Inventory (Short Form) (BPI-SF)
  • Neuropathic Pain Scale (NPS)
  • Patients' Global Impression of Change Scale
  • Short-Form McGill Pain Questionnaire (SF-MPQ)
  • Pain Catastrophizing Scale
  • Profile of Mood States Short Form
  • North Central Cancer Treatment Group Patient Quality-of-Life Linear Analog Self-Assessment Scale

Results:

  • Average weekly pain intensity ratings were not significantly lower while patients used the lidocaine patch versus the placebo.
  • BPI-SF interference scores were lower in patients receiving the lidocaine patch in the first period: general activity (p = 0.02), work (p = 0.04), relations with others (p = 0.02).

Conclusions:

Pain interference scores were significantly lower in the group that received lidocaine patch first. Significant differences in postsurgical pain intensity, with the lidocaine patch applied to incisional areas, were lacking overall.

Limitations:

  • The number of patches used varied.
  • The study lacked power.
  • Patients self-reported pain by means of telephone and email. Patients applied the patches themselves; whether they applied them correctly is unclear.
  • In regard to weekly measures: Change may have occurred at times when measurements were not taken.

Nursing Implications:

Further research is needed to determine whether lidocaine patches augment the analgesic regimen for incisional pain.

Ismail, M.A., Kamal, A.M., Ghobashy, S., Al Baz, A.G., & Roshdy, M. (2015). Comparison of pain control during Trus guided biopsies between basal peri-prostatic local infiltration anesthesia versus combined topical anal lignocaine ointment and local infiltration anesthesia. Journal of the Egyptian Society of Parasitology, 45, 285–289.

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Study Purpose:

To compare two techniques for pain relief with ​transrectal ultrasonography (TRUS)-guided biopsies

Intervention Characteristics/Basic Study Process:

Patients undergoing prostate biopsies were randomized to receive either local infiltration anesthesia alone or a combination of local anesthesia and lignocaine 5% ointment to the anal rind, canal, and anterior rectal wall. Patients were asked to rate pain during insertion, during infiltration, and after biopsy.

Sample Characteristics:

  • N = 163
  • MEAN AGE = 61.7 years (range = 50–88 years)
  • MALES: 100%         
  • KEY DISEASE CHARACTERISTICS: All had elevated prostate-specific antigens

Setting:

  • SITE: Single site  
  • SETTING TYPE: Not specified  
  • LOCATION: Egypt

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Diagnostic

Study Design:

Randomized trial

Measurement Instruments/Methods:

  • 100 mm Visual Analog Scale (VAS) for pain

Results:

Patients who received a combination of local and topical anesthesia reported significantly less pain (p = 0.005) at all stages of the procedure.

Conclusions:

The combination of a local anesthetic infusion with a topical anesthetic may provide better pain control during biopsy.

Limitations:

  • Risk of bias (no blinding)
  • Measurement/methods not well described
  • Measurement validity/reliability questionable
  • Other limitations/explanation: Data regarding pain differences were reported using different numeric scales, so the actual method of measurement and resulting analysis was unclear. It was unclear how patients during biopsy could reasonably use the VAS to report pain.

Nursing Implications:

The combination of anesthetic infiltration and a local topical anesthetic may reduce pain during biopsy.

O'Connor, J.M., Helmer, S.D., Osland, J.S., Cusick, T.E., & Tenofsky, P.L. (2011). Do topical anesthetics reduce periareolar injectional pain before sentinel lymph node biopsy? American Journal of Surgery, 202(6), 707–711; discussion 711–122.

doi: 10.1016/j.amjsurg.2011.06.040
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Study Purpose:

 To determine whether lidocaine-prilocaine cream decreases injection pain related to sentinel lymph node biopsy

Intervention Characteristics/Basic Study Process:

Eligible subjects were randomized to either the treatment or control group, then provided with a syringe that contained either the study medication (lidocaine-prilocaine cream) or a placebo cream that looked identical to it. Subjects also received instructions on how to apply the cream and a copy of the postprocedure survey, which asked patients to evaluate ease of application as well as level of pain. The subjects were to apply the given cream and then a barrier dressing to the area. Patients went to one of three radiology departments to receive an injection of the Tc sulfur colloid for the sentinel lymph node biopsy. Postoperatively, over the telephone, the patients completed the survey with help from a researcher. 

Sample Characteristics:

  • The sample was composed of 39 patients.
  • All patients were older than 18 years.
  • All the patients were female.
  • All the patients had breast cancer
     

Setting:

  • Multisite
  • Inpatient and outpatient settings
     

Phase of Care and Clinical Applications:

Phase of care: active treatment

 

Study Design:

Triple-blinded prospective randomized placebo-controlled trial

Measurement Instruments/Methods:

  • Scale measuring ease of cream and dressing application, a five-point Likert-type scale    
  • 10-point pain scale, to measure pain
  • A tool that recorded whether patient would recommend cream (yes/no)
     

Results:

Thirty-nine subjects completed the study. Subjects from both groups rated the cream as easy to apply, and both groups responded similarly in regard to dressing retention. Authors reported no significant difference in median injectional pain scores between the treatment and control groups. Authors noted two trends: The treatment group was more likely than the control group to recommend the cream, and the control group was more likely to rate the injection as painful or extremely painful.

Conclusions:

The pain scores of subjects who received the lidocaine-prilocaine cream were not significantly lower than those of the control group.

Limitations:

  • The study had a small sample size, with fewer than 100 patients.
  • The study comprised variability in injection techniques and volumes.
  • Study design was based on the prediction of a large difference (4) between the two groups on a 10-point Likert scale.  
     

Nursing Implications:

This study does not indicate that a topical anesthetic, lidocaine-prilocaine cream, had a significant effect on injectional pain; however, the finding may be a consequence of the study design. Further studies, with larger sample sizes and smaller predicted differences in the study groups, may produce a different result.

Oz, M., Korkmaz, E., Cetinkaya, N., Bas, S., Ozdal, B., Meydanl, M.M., & Gungor, T. (2015). Comparison of topical lidocaine spray with placebo for pain relief in colposcopic procedures: A randomized, placebo-controlled, double-blind study. Journal of Lower Genital Tract Disease, 19, 212–214. 

doi: 10.1097/LGT.0000000000000099
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Study Purpose:

To evaluate the effectiveness of topical lidocaine spray for pain relief during cervical punch biopsies and endocervical curettage (ECC)

Intervention Characteristics/Basic Study Process:

Women with abnormal cervical cytology requiring colposcopy-directed cervical biopsy with or without ECC were randomly assigned to receive 10% lidocaine or normal saline spray to the ectocervix prior to colposcopy.

Sample Characteristics:

  • N = 214   
  • MEAN AGE = 24.25 years
  • FEMALES: 100%
  • CURRENT TREATMENT: Not applicable

Setting:

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Turkey

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Diagnostic

Study Design:

  • Double-blind, placebo-controlled, randomized, controlled trail

Measurement Instruments/Methods:

  • Wong-Baker FACES Pain Rating Scale

Results:

No significant difference in pain scores between groups was reported.

Conclusions:

The use of sprayed local anesthetic prior to colposcopic punch biopsy did not reduce procedure-related pain.

Limitations:

  • Measurement/methods not well described
  • Measurement validity/reliability questionable
  • Exactly when pain was measured is unclear.
  • No subgroup analysis between those who also had ECC and those who did not

Nursing Implications:

The use of a topical anesthetic spray prior to colposcopic procedures as studied here did not demonstrate effectiveness in reducing postprocedure pain. Further research is needed to determine the best approaches to reduce or eliminate pain associated with this type of procedure.

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