Local Cream Research Articles

Pain-management strategies for cosmetic injectable treatments: an overview

Some of the most prevalent methods of reducing the discomfort associated with cosmetic injectable treatments include topical anaesthetic application and facial blocks. The clinician's choice of needle for both botulinum toxin and dermal filler injections is significant, as is the choice of cannula. Facial blocks and infiltration techniques appear to provide significant relief in terms of efficacy and safety, particularly in sensitive areas, such as the perioral region. However, the success of these methods rests on possessing a sound technique and an accurate knowledge of facial anatomy. A variety of topical anaesthetic creams offer an alternative means of alleviating discomfort. This article reinforces the need for aesthetic practitioners providing non-surgical procedures to be adept at delivering a number of pain-relieving strategies, dependent on patient preference, the anatomical area being treated, and the chosen product or treatment.

Vestibulitis: a medic's struggle with vulval pain from the other side of the curtain.

Going to the doctor about ‘women’s things’ is never pleasant but it’s even worse when, despite everyone’s best efforts, your symptoms remain unexplained. I’ve decided to share my personal experience of vestibulitis, under the guidance of GP Anjana Singh and consultant gynaecologist Gabrielle Downey, in order to raise awareness and facilitate prompt diagnosis for future patients. On 10 September 2013 I lay on the trolley in an anaesthetic room, petrified at the thought of having surgery but also excited about what the operation would hopefully achieve. Earlier that year I had been in the very same room as a 3rd year medical student, observing the anaesthetic induction of a patient who was about to undergo a procedure called a Fenton’s vestibulectomy. The gynaecologist explained that the procedure was for a specific type of dyspareunia called vestibulitis. She diagnosed this by the relief of pain after the application of local anaesthetic cream around the introitus. At this point my mind was racing; I had been experiencing superficial dyspareunia that was relieved by the use of local …

Paediatric vascular access

### Key points Obtaining reliable vascular access in small children is frequently made challenging by anatomical factors—in particular, small, mobile veins and an excess of subcutaneous fat which make visualization and palpation of veins difficult. Paediatric patients are often less co-operative, and the potential for psychological trauma, especially with repeated procedures in the conscious patient, further complicates matters. Short-term vascular access is frequently required in hospitalized children for the delivery of i.v. fluids, medication, and blood product administration. Longer-term vascular access devices are required for repeated medication delivery (e.g. enzyme replacement therapy in inherited metabolic diseases), chemotherapy, immunotherapy, total parenteral nutrition, and extracorporeal procedures such as plasmapheresis and haemodialysis. In addition, vascular access devices may be needed for repeated blood sampling and invasive haemodynamic monitoring. The choice of vascular access device depends upon the condition and preference of the patient or parent/guardian, the likely duration and frequency of treatment, and the properties of the infusate. Infusates with vesicant properties (drugs with the potential to cause blistering with tissue injury, e.g. calcium solutions and amphotericin B), hypertonic solutions, and those with pH 9 will necessitate central venous access. Vasopressors and inotropes are preferentially administered centrally as they require reliable access and extravasation may cause tissue necrosis. It is important to try to predict future needs for vascular access as poor prospective management …

Improvement of hand sensibility resulting from application of anaesthetic cream on the forearm: importance of dose and time

Introduction A local anaesthetic cream, EMLA®, applied temporarily to the forearm can improve sensory functions in the hands, both in healthy individuals and in patients with nerve injury. The treatment concept is an example of guided plasticity where the dynamic capacity of the central nervous system is used for therapeutic purposes. However, the optimal dose and duration of the anaesthetic cream is not known and this is addressed here. Methods Sixty healthy volunteers participated in this experimental study. They were randomised to one of six groups of 10 and received either 10 g or 20 g of EMLA® on the volar part of the forearm for either 60, 90 or 120 min, respectively. Outcome measures were touch thresholds and discriminative touch in digits II and V. Results There was a statistically significant improvement in touch threshold as well as discriminative touch in all six groups. However, there were no statistically significant differences between the six different dose and duration combinations. Conclusions It is concluded that 10 g of EMLA® applied to the volar part of the forearm for 60 min may be adequate to induce improved hand sensibility.

Local anaesthetic systemic toxicity

Access the CPD MCQs for this issue online here ### Key points Well-placed local anaesthetics (LAs) can yield great clinical benefits. But systemic toxicity related to their use can be devastating. The highly publicized case in 2004 of Mayra Cabrera, a theatre nurse who died shortly after delivery of her baby boy when her epidural infusion of bupivacaine was mistakenly connected to her i.v. line, reminds us to be vigilant and to learn from such rare events. While prevention is clearly the most important element in avoiding morbidity and mortality associated with local anaesthetic systemic toxicity (LAST), such cases still occur despite best practice. Knowing how to manage these uncommon events is vital. In this review, we cover LA toxicity, its incidence, clinical features, risk factors, prevention, and management and examine i.v. lipid emulsion (ILE) therapy in more detail. LAST has been recognized for more than a hundred years, but the precise incidence is currently unknown. In 1928, the American Medical Association reported 40 deaths attributable to LAs.1 Cocaine was responsible for half of these deaths, but procaine was also implicated. These findings prompted the search for less toxic agents. Lidocaine, first synthesized in 1944, was the first amide LA to be used clinically. However, in 1979, the potentially fatal toxicity of amide LAs was highlighted by Albright.2 More recently, studies from 1993 …

The contribution of sensory nerves to cutaneous vasodilatation of the forearm and leg to local skin heating.

The initial cutaneous vasodilatory response to local skin heating is larger in the forearm than the leg. While the initial vasodilatation of the forearm to local heating is primarily dependent on sensory nerves, their role in the leg is unknown. We compared the contribution of sensory nerves in driving the cutaneous vasodilatory response of the forearm and leg to local heating using local anaesthetic (EMLA) cream. In seven participants, two skin sites were selected on both the dorsal forearm and anterolateral calf; one site on each region received EMLA, with the other an untreated control. All sites were controlled at 33 °C and then locally heated to 42 °C with integrated laser-Doppler local heating probes. Cutaneous vascular conductance (CVC) during the initial vasodilatation to local heating was smaller in the leg (47 ± 9% max) compared to the forearm (62 ± 7 % max) (P = 0.012). EMLA reduced the initial vasodilatation at both the leg (27 ± 13 % max) (P = 0.02) and forearm (33 ± 14% max) (P < 0.001). The times to onset of vasodilatation, initial vasodilatory peak, and plateau phase were longer in the leg compared to the forearm (all P < 0.05), and EMLA increased these times in both regions (both P < 0.05). CVC during the plateau phase to sustained local skin heating was higher in the leg compared to the forearm at both the untreated (93 ± 6 vs. 85 ± 4% max) (P = 0.33) and EMLA-treated (94 ± 5 vs. 86 ± 6% max) (P = 0.001) sites; EMLA did not affect CVC (P > 0.05). The differences in the initial vasodilatory peak to local skin heating between the forearm and the leg are due to the contribution of sensory nerves.

Intersphincteric infection due to an anal fissure

Dear Editor: Anal fissure is a linear ulcer in the squamous epithelium of the distal anal canal, usually located in the posterior midline. Its etiology is not clear yet, but the ischemic cause remains the most commonly supported theory. Pain during defecation is the main symptom indicated by patients, while on physical examination, spasm of the anal canal is a common finding. Although patients may complain of periodic episodes suggesting chronicity, most of the anal fissures at first presentation heal with lifestyle measures, laxatives, and local ointments. Chronicity is widely defined by both chronology and morphology. However, in spite of these treatments, some patients develop a chronic fissure, but so far, the real reason of unhealed fissures has not been investigated. In our practice, we have seen several cases where chronic anal fissure developed into an intersphincteric abscess. The literature is scarce about the subject. Three studies proposed a theory that a chronic anal fissure is the clinical and pathological expression of a coexisting intersphincteric or low transsphincteric fistula [1–3]. Herein, we present a case with anal ultrasound in which a chronic fissure developed into an abscess. A female patient who suffered from anal pain since 3 months was referred to our outpatient clinic. She stated that the pain started after passing hard stools. Her general practitioner had treated her with mononitrate (diltiazem) ointment and macrogol. However, the anal pain persisted and occurred daily during defecation. Her medical history included asthma for which she used inhalation medication with corticosteroids. She had two vaginal births; during the first, an episiotomy was performed. At physical examination, there were no signs of general illness. The peri-anal skin was normal; there was no swelling. A fissure in the posterior midline was noticed. Rectal examination was hardly possible due to the pain, and hypertonia of the (internal) anal sphincter was present. During vaginal examination, there was no suspicion for any pararectal abscess nor signs of dyssynergy of the pelvic floor. Transanal ultrasound revealed a hypo-echogenic reflection in the mucosa that matched a fissure. The macrogol was continued, the topical treatment with diltiazem ointment increased to three times a day to be explicitly applied into the anus. Furthermore, we prescribed oral analgesics and explained the paradoxical functioning of the puborectal muscle during pain and the importance of avoiding straining. After 4 weeks, her pain had almost disappeared. She still used oral analgesics on demand but stopped using the diltiazem. Six weeks later, she returned because the pain had increased. At that time, the pain was continuously present despite the use of oral analgesics. Anal examination revealed a small sentinel polyp posteriorly and hypertonia of the (internal) anal sphincter. On transanal ultrasound, we now saw a hypo-echogenic area posteriorly suspicious for an intersphincteric infection. She was administered oral antibiotics (amoxicillin/clavulanic acid 625 mg), to be taken three times a day during 2 weeks. Three weeks later, she presented with ongoing pain and a painful swelling posterior of the anus. At rectal examination, a * Richelle J. F. Felt-Bersma rjf.felt@vumc.nl

The characterization, current medications, and promising therapeutics targets for premature ejaculation.

Premature ejaculation (PE) is the most prevalent male sexual dysfunction. This is associated with negative personal and interpersonal psychological outcomes. The pharmacologic treatment of PE includes the use of antidepressants, local anesthetic agents, and phosphodiesterase type 5 inhibitors. While numerous treatments can control PE, only antidepressants and topical anesthetic creams and sprays have recently been shown to be more effective. This review focuses on the physiology and pharmacology of ejaculation, the pathophysiology of PE and the most effective pharmacological treatment of PE. Pharmacotherapy of PE with off-label short-acting selective serotonin reuptake inhibitors (SSRIs) is common, effective, and safe. Dapoxetine, a SSRI with a short half-life, has been recently evaluated for the treatment of PE by several countries and results are promising. In clinical practice, follow-up side effects are an important part of the management strategy for PE. The understanding of etiology, pathophysiology, and treatment modalities of PE would be beneficial to clinician in helping patients with this disappointing sexual problem.

Allopurinol induced stevens - johnson syndrome - a case report.

A 43-year old female from rural area was admitted in a tertiary care hospital complaining of sudden development of rash all over the body since last four days. Initially rash developed over abdomen and chest followed by spreading to rest of the portion of the body including palm and soles. Skin rashes were initially erythematosus and maculopapular and extremely itchy followed by painful blister formation, affecting mucous membrane of mouth [Table/Fig-1], anal canal, and vaginal area also. There was denudation with raw ulceration at places over face following rupture of blisters during hospital stay [Table/Fig-1,​,2].2]. Patient was unable to eat due oropharyngial painful ulceration and crusting over lips. Then purpuric macules or blisters appeared over trunk, abdomen and back [Table/Fig-3]. There was no history of similar sort of episode in the past. [Table/Fig-1]: Shows oedema and crusting of the lips with erythematous purpuric macular lesions, which typically first appear on the face and thorax before spreading to other areas [Table/Fig-2]: Atypical target-like or targetoid lesions in a patient with SJS characterized by purpuric macules or blisters [Table/Fig-3]: Healed purpuric macules or blisters on the back On examination, the patient was alert and appeared dehydrated. Her body temperature was 38°C, blood pressure was 114/70 mm Hg, pulse rate was 96 beats per minute, and respiratory rate was 20 breaths per minute. Nikolsky’s sign was positive. The body surface area involvement of the patient at the time of presentation was 9%. Patient was suffering from multiple joint pains since last one month for which she was taking allopurinol 100 mg thrice daily for last ten days prior to development of skin rash. Patient’s body temperature was also increased to 39.4°C intermittently which diminished on paracetamol administration following three days after admission. The patient’s complete blood count was within normal limits except slight decreased haemoglobin concentration 10.4 g/dL. Erythrocyte sedimentation rate (ESR) was normal. Her C-reactive protein was increased to 7.6 mg/dL. The serum levels of total protein, albumin, blood urea nitrogen, creatinine and elevated random blood glucose were within normal limits. Serum total IgE and ECG were normal. The sodium and potassium levels were slightly decreased. There was no evidence of eosinophilia and levels of liver enzymes and serum bilirubin were within the normal range. Blood culture was negative. The serological titers for HSV was within normal limits, exclude the possibilities of HSV infection in etiopathogenesis in this particular case. Skin biopsy was advised in order to rule out differential diagnoses such as autoimmune blistering diseases like pemphigus vulgaris, bullous fixed drug eruption, erythema multiforme acute generalised exanthematic pustulosis and TEN. Treatment was started conservatively with oral antihistaminic 25 mg, antipyretics, intravenous dexamethsone and intravenous fluid therapy. The patient was started antibiotic inj. cefotaxime 1gm i.v. to reduce the risk of secondary infection, skin lesions were treated with topical therapy and local anaesthetic creams. Chlorhexidine rinse was given to maintain good oral hygiene and white-soft paraffin was applied on the lips to relieve pain. The lesions gradually diminished and healed up in about 15 days [Table/Fig-4] and resolved with mild hypo/ or hyperpigmented spots. The causality assessment as per the Naranjo algorithm [1] revealed the ADR to be Probable (Naranjo score 7). Assessment of causality by using the algorithm of drug causality for epidermal necrolysis (ALDEN) [2] was ‘very probable’. Severity-of-illness and prognosis was assessed by using the SCORTEN criteria. We did not seek to test the effects of re-challenge in our patient. Patient and relatives was properly counselled. [Table/Fig-4]: Healed purpuric macules or blisters on the face and trunk

外用局所麻酔剤リドカイン・プロピトカイン配合クリームのレーザー脱毛時における有用性の検討

外用局所麻酔剤リドカイン・プロピトカイン配合クリームのレーザー脱毛時における有用性の検討

Topical EMLA Cream as a Pretreatment for Facial Lacerations.

BackgroundTopical anesthetics, such as eutectic mixture of local anesthetics (EMLA) cream, can be applied to reduce pain before minor procedure. This trial evaluated EMLA as pretreatment for facial lacerations and compared pain, discomfort and overall satisfaction.MethodsThis trial included consecutive emergency department patients ≥16 years of age who presented with simple facial lacerations. At triage, lacerations were allotted to either the routine processing group or EMLA pretreatment group according to date of admission. Initially, the emergency department doctors inspected each laceration, which were dressed with saline-soaked gauze. In the pretreatment group, EMLA cream was applied during wound inspection. The plastic surgeon then completed primary closure following the local injection of an anesthetic. After the procedure, all patients were given a questionnaire assessing pain using the 10-point visual analog scale (VAS) ("no pain" to "worst pain"). All questionnaires were collected by the emergency department nurse before discharge.ResultsFifty patients were included in the routine processing group, and fifty patients were included in the EMLA pretreatment group. Median age was 39.9 years, 66% were male, and the average laceration was 2.67 cm in length. The EMLA pretreatment group reported lower pain scores in comparison with the routine processing group (2.4 vs. 4.5 on VAS, P<0.05), and lower discomfort scores during the procedure (2.0 vs. 3.3, P=0.60). Overall satisfaction was significantly higher in the EMLA pretreatment group (7.8 vs. 6.1, P<0.05).ConclusionsPretreating facial lacerations with EMLA topical cream aids patients by reducing pain and further enhancing overall satisfaction during laceration treatment.

Outpatient pediatric dermatologic surgery: experience in 296 patients.

From January 2010 to December 2012, 296 skin biopsies were performed in pediatric patients using only local anesthesia (cream and infiltration). The biopsies were divided into three groups: biopsies of skin neoplasms, biopsies of skin rashes and biopsies of follicular-centered lesions. Our data demonstrate the possibility of using this procedure, with the dual advantage of eliminating hospitalization and cost savings.

Optimizing pediatric venipuncture: ensuring successful blood sample collection with minimal stress and pain

Methods At the Vancouver site of the CHILD study, we reviewed and compared current topical anesthetic creams used for pediatric venipuncture, specifically Ametop Gel (tetracaine hyrdrochloride gel 4%) versus EMLA (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%). We conducted regular in-service training to ensure all members of the study team were informed and educated in understanding the importance of collecting the blood sample and dealing with pediatric populations at different developmental stages. Training also addressed parental anxiety related to the procedure and strategies to establish rapport and trust were shared. Finally, we developed a repertoire of comfort and distraction techniques to support the child, the parent, and the phlebotomist. We used quantitative and qualitative approaches to assess outcomes, including the number of blood samples successfully collected at the 1 and 5 year clinic visits and analysis of responses to our parent satisfaction survey evaluating perceptions of the venipuncture procedure.

Management of childhood pain and healthcare providers’ willingness to use topical anaesthetic cream for minor procedural pain in Nigeria

Objective: To determine providers’ willingness to use (WTU) topical anaesthetic cream (TAC) to alleviate childhood pain. This information will be useful for successful implementation of TAC in Nigeria.Subjects and Methods: The study was undertaken in hospitals in southeast Nigeria. Intervieweradministered questionnaire was used to collect information: on the providers’ preferred waiting time and their WTU TAC. Likert scale was used to assess the providers’ level of uneasiness when performing painful procedures and their WTU the TAC. Multiple regression analyses were performed to measure the relationship of WTU with the different independent variables, after creating a binary option for some variables.Results: Providers surveyed were 232. Majority (94.8%) wanted the pain alleviated and 87.9% had made some attempts to alleviate the pain. Only one respondent (1%) knew about TAC, but none had used it before. Over 94% of the respondents were WTU TAC. The mean maximum preferred waiting time was 37.03 minutes. Many (68.8%) were concerned about the prolonged waiting time required and 19.8% and 12.5% with its availability and affordability respectively. In linear multivariate analyses, WTU was not statistically associated with designation, age, average weekly procedure and scale-rating of the childhood pain (p &gt; 0.05).Conclusion: The WTU TAC was high, but the mean time willing to wait was lesser than mean recommended time of 45 minutes. If this latter limitation is circumvented, it may aid implementing the use of TAC in routine pediatric care.Keywords: Nigeria; Willingness to Use; Topical Anaesthetic Cream; Providers.

The use of eutectic mixture of lidocaine and prilocaine in mice (Mus musculus) for tail vein injections

ObjectiveTo investigate a topical local anesthesia technique as a means to prevent and/or diminish pain in mice in a laboratory setting associated with tail vein injections performed by personnel in training. Study designProspective, randomized experimental trial. AnimalsThirty six adult female, 23–28 g CD-1 mice from an in-house training colony. They were acclimated to routine training and handling classes. MethodsEutectic mixture of local anesthetics (EMLA) cream (2.5% lidocaine/2.5% prilocaine) or a bland ointment control (n = 18) was applied on the tail prior to intravenous injection. The injections were performed by novices, who had never attempted the procedure, and experienced personnel. All participants were blinded to treatment groups. Three injection attempts were allowed per animal. The mice were observed and scored by blinded evaluators for behavioral and physiological changes, including respiratory rate, vocalization, tail flick, and escape behaviors, during and after the injection. ResultsThis study demonstrates that aversive behaviors induced by lateral tail vein injection were not changed by the preemptive application of EMLA cream. The aversive behaviors associated with lateral tail vein injection were significantly affected by the number of injection attempts and the individual's experience level. Conclusions and clinical relevanceTopical EMLA cream did not reduce signs of aversive reaction to tail vein injection and thus we did not find support for its use in mouse training programs for tail vein injections.

PS-346 Improving The Standard Of Invasive Procedures In Paediatrics - A Teaching Intervention To Align Current Practice To British Psychological Society Guidelines

Background/aims Invasive procedures (eg intravenous cannulation) remain a leading cause of distress in children. They are performed daily yet rarely taught formally, leading to variation in practice. The British Psychological Society (BPS) created guidelines in 2010, although these have yet to be implemented in a formal teaching programme. Our teaching intervention aimed to align practice to BPS guidelines and improve professional confidence. Methods Teaching sessions were delivered to professionals involved in cannulation at two South London hospitals by a senior play specialist and a paediatrician. Sessions covered assessment, preparation, teamwork, implementation and post-procedural care. A poster containing a flowchart was used for teaching and departmental reference. Results Thirteen professionals involved in cannulation (9 medical, 4 nursing) reported their previous teaching experiences. 5 reported never receiving training in paediatric invasive procedures, 6 informal teaching and only 2 receiving formal teaching (1 medical, 1 nursing). Pre-intervention confidence was 5.7/10 (n = 13) [range 0–8]. This improved to 7.3/10 [range 4–9] post intervention. The intervention usefulness was rated 8.3/10 (n = 12, range 5–10]. When self-reporting practical considerations for cannulation, 8/12 mentioned local anaesthetic creams but only 6/12 mentioned using distraction or a play specialist. Conclusions This intervention aimed to address the lack of formal teaching available in Paediatric invasive procedures. It highlighted areas of BPS guidance that remain underappreciated despite their greater efficacy (eg the importance of distraction vs anaesthetic cream). Initial levels of confidence showed improvement post-intervention. We recommend this teaching intervention to be used regularly throughout Paediatric departments and undergraduate medical programmes.

Randomized double-blind clinical trial of eutectic mixture of local anesthetic creams in reducing pain during hysterosalpingography.

Background:Hysterosalpingography (HSG) is considered as a primary test in infertility work up worldwide due to its reliability in evaluating abnormalities related to the uterus and fallopian tubes.Objectives:To assess the efficacy of applying eutectic mixture of local anesthetics (lidocaine-prilocaine cream) (EMLA) on the uterine cervix in reducing pain during HSG.Patients and Methods:Eighty patients undergoing HSG as part of infertility evaluation were randomly allocated to groups receiving either EMLA (N = 40) or placebo cream (N = 40) in a double-blinded prospective study. Fifteen minutes before HSG, 5 grams of 5% cream was applied to the uterine cervix using a cervical applicator. The degree of pain experienced by the patient was evaluated during and after HSG at five predefined steps on a visual analogue scale (VAS).Results:There was no significant difference in the efficacy between EMLA and placebo creams in pain perception during the entire procedure. There was no significant difference in long term pain perception half an hour after the HSG performance.Conclusions:This study does not support the use of EMLA for HSG.

Prospective Evaluation of Fractional CO2 Laser Treatment of Mature Burn Scars.

The authors conducted a prospective study of fractional CO2 laser treatment of mature burn scars, comparing objective and subjective scar measurements evaluating at least one treatment and one control scar on the same patient pre- and post treatments. After institutional review board approval, burn survivors with mature blatant burn scars were invited to enter the study. A series of three fractional CO2 laser treatments was performed in an office setting, using topical anesthetic cream, at 40 to 90 mJ, 100 to 150 spots per cm(2). Subjective and objective measurements of scar physiology and appearance were performed before and at least 1 month after the treatment series on both the treated and the control scar. A total of 80 scars, 48 treatment and 32 control scars, were included in the study. Treatment pain score averaged at 4.7/10 during and at 2.4/10 5 minutes after the treatment. All treated scars showed improvement. Objectively measured thickness, sensation, erythema, and pigmentation improved significantly in the treated scars (P = .001, .001, .004, and .001). Elasticity improved, but without statistical significance. Vancouver scar scale assessments by an independent observer improved from 8 to 6; patient self-reported pain and pruritus remained unchanged in both groups. Fractional CO2 laser treatment is a promising entity in the treatment of burn scars. Our study results show significant differences in objective measurements between the treated scars and the untreated control scars over the same time period. In scar treatment studies, the patient/observer and Vancouver scar scales may not be sensitive enough to detect outcome differences.

Advances in treating premature ejaculation.

In spite of its high prevalence and long history, the ambiguity regarding the definition, epidemiology and management of premature ejaculation continues. Topical anesthetic creams and daily or on-demand selective serotonin reuptake inhibitor (SSRI) treatment forms the basis of pharmacotherapy for premature ejaculation today, in spite of low adherence by patients. Psychotherapy may improve the outcomes when combined with these treatment modalities. Tramadol and phosphodiesterase type 5 inhibitors have a limited role in the management of premature ejaculation. Further research is required to develop better options for the treatment of this common sexual disorder.

The efficacy, safety, and subject satisfaction of pain management of a self-occlusive topical anesthetic cream during and after filler injections for the correction of nasolabial folds

The efficacy, safety, and subject satisfaction of pain management of a self-occlusive topical anesthetic cream during and after filler injections for the correction of nasolabial folds