PRACTICAL PEARLS FOR NEARLY PAINLESS
JOHN K. GEISSE, MD
SOLANO DERMATOLOGY ASSOCIATES
2290 SACRAMENTO STREET
VALLEJO, CA 94590
DEPARTMENTS OF DERMATOLOGY
UNIVERSITY OF CA, SAN FRANCISCO
PRACTICAL PEARLS FOR NEARLY PAINLESS LOCAL
1. Benzodiazepines: PO or sublingual
* IV precautions with sublingual
1. PO Codeine/hydrocodone acetaminophen
2. IM narcotics need IV precautions
a. Naloxone, epinephrine, and crash cart
1. PO or IM hydroxyzine no longer
available have not found a
D. VALIUM 5-10 MG SL PLUS RARELY
DEMEROL 50-100 MG FOR
PROLONGED OR DIFFICULT CASES.
II. TOPICAL ANESTHETICS
A. Benzocaine compounds: Intraoral or mucosal
1. Pina Colada
B. Lidocaine gels and EMLA
1. Prior to needle puncture, laser therapy and
III. Local Anesthesia
A. Lidocaine +/- epinephrine.
1. Buffered: 1 part sodium bicarbonate (8.4% or
1 mEq/ml) to 9 (10) parts 1% lidocaine with
B. Longer acting anesthetics relative to lidocaine:
1. Mepivacaine: faster, longer, and safer. $$
2. Prilocaine: slow, methemogobinemia.
3. Bupivacaine: slower, longer (up to 4 hr. block).
4. Etidocaine: ideal, better than bupivacaine. $$
1. Allergy; very rare to amides; usu vasovagal
2. Systemic side effects: CNS, cardiovascular,
pregnancy-toxicity to fetus
3. Maximum recommended dosages:
a. Lidocaine with epinephrine:
Adults; 7.5 mg/kg, 500 mg total
(50 ml of 1% with epi; only 25ml without epi)
Children; 1.5-2.5 mg/kg (0.5% recommended)
4. Epinephrine and Beta Blockers; dilute to
1:200,000 (hypertensive crisis, headache)
. Most “toxicity” is from the epinephrine effect
REMEMBER: LIDOCAINE TOXICITY IS NOT
LINEARLY DOSE RELATED
1. E.G. 2% lidocaine has greater toxicity
than 1% without significantly greater
efficacy (50ML 1% Lido= 12ML 2%
2. 2% for blocks only
3. 0.5% LIDO FOR CHILDREN OR LARGE
4. Tumescent anesthesia has different
parameters; absorption peak 12hrs
– 1. Diphenhydramine (12.5-5-25mg/ml) with
epinephrine 1; 200,000.
– 2. Normal Saline preserved with benzyl alcohol
a. can add epi for prolonged effect
– 3. Refrigerant sprays and ice cubes.
IV. INJECTION TECHNIQUE
A. Regional Blocks:
2. Digital: Beware of vascular compromise,
metacarpal method preferred
B. Subcutaneous vs. Intradermal injection:
Hurried anxiety producing behavior;
Sudden needle sticks (the “stab” technique);
Forceful or rapid tissue infiltration causing tissue distension,
especially with intradermal injection;
Injection of plantar/palmer surfaces (use blocks and lateral
Avoid hitting bone with the needle
A. “Painless Anesthesia”
1. 30 gauge needles; 1 inch long
2. Injection through cutaneous pores
3. Slow, careful infiltration; infiltrate as one
advances the needle slowly, subq first
4. Distraction: massage or vibration;
an assistant who “hand holds” and chats with
5. Buffered lidocaine and freshly mixed
6. Reinject in anesthetized areas; minimize sticks
* Painful experiences and poor or
prominent surgical scars are the two
most memorable aspects of a surgical
procedure for a patient. If one can
provide a nearly painless surgical
procedure without the use of general
anesthesia than you have won half
1. Auletta MJ, Grekin RC: Local Anesthesia For Dermatologic Surgery. From the series
Practical Manuals In Dermatologic Surgery, Churchill Livingstone, 1990.
2. Grekin RC, Auletta MJ: Local Anesthesia in Dermatologic Surgery. J AM Acad Deramtol
3. McKay W, et al: Sodium bicarbonate attenuates pain on skin infiltration with lidocaine
with or without epinephrine. Anesthesia Analogues pp. 572-574, 1987.
4. Stewart JH, et al: Neutralized Lidocaine with epinephrine for local anesthesia. J
Dermatol Surg Oncol 15:10, 1989
5. 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 16:11, 1990.
6. Lahteenmaki T, et al: Topical analgesia for the cutting of split-skin grafts: a multicenter
comparison of two doses of a lidocaine/prilocaine cream. Plastic and Reconstr Surg 82:3,
7. Physicians Desk Reference, 45th edition, 1991.
8. Bennett RG: Fundamentals of Cutaneous Surgery, C.V. Mosby Company, 1988.
9. Larson PO, et al: Stability of Buffered Lidocaine and Epinephrine Used for Local
Anesthesia. J Dermatol Surg. Oncol 1991; 17:411-414.