Leg ulcer progression caused by topical anesthesia with EMLA^® cream

Abstract

While treating a 63-year-old woman with leg ulcerations, we observed an unusual phenomenon. A wound débridement was planned to remove adherent necrotic material. After topical anesthesia with a lidocaine-prilocaine mixture (EMLA cream) a hemorrhagic,livid margin area developed around the ulcer 90 minutes after application. The area turned necrotic over days and the center was débrided. A more detailed history revealed that similar necrosis had occurred previously when EMLA cream had been employed. We interpreted the current event,as well as the past episodes,as a pathological reaction of the small cutaneous blood vessels to EMLA cream. The history also revealed an overlap connective tissue disease with microvascular impairment. After exposure to the topical anesthetics, the pre-damaged cutaneous blood vessels presumably produced a critical ischemia with subsequent necrosis. Based on this case, we recommend careful use of EMLA cream with frequent monitoring for necrosis when treating patients with a known disorder of microcirculation.

Analgesic efficacy of equimolar 50% nitrous oxide/oxygen gas premix (Kalinox®) as compared with a 5% eutectic mixture of lidocaine/prilocaine (EMLA®) in chronic leg ulcer debridement

“…Topical analgesia with lidocaine/prilocaine is a widely used and effective method for painful dressing changes and sharp mechanical leg ulcer debridement . Side effects such as leg ulcer progression because of vasoconstrictive effects are described but are very rare . In our experience, the only limitation of topical 5% lidocaine/prilocaine at times is occasional insufficient pain control, thus leading to early cessation of the planned procedure.…”

Microcirculatory effect of topical vapocoolants

“…In addition, the cost per treatment with EMLA is significantly higher than with vapocoolants. Finally, there are rare side effects associated with EMLA, including irritation to mucous membranes, hemorrhages and tissue necrosis for those patients with small vessel disease related to hypertension, diabetes mellitus and/or sepsis (23,24).…”

Schmerzreduktion bei Patienten mit chronischem Ulcus cruris durch ein neu entwickeltes Morphingel

“…Zwar sind direkte Kontaktsensibilisierungen auf Amid-Lokalanästhetika wie Lidocain und Prilocain eher selten zu finden, aber es wurden dennoch bereits mehrere Berichte über Kreuzreaktionen zwischen Prilocain und anderen Amiden publiziert [28]. Darüber hinaus berichteten Stahl et al [27] 2008 über das Auftreten von Wundrandnekrosen und somit einem Fortschreiten eines Ulkus nach Applikation von EMLA-Creme. Als pathophysiologisch relevant wurde eine gestörte Reaktion der kleinen Hautgefäße vermutet, die zu einer Schädigung der Mikrovaskularisation führt.…”