Use Plain Lidocaine 2% for Steroid Injections
For steroid injections, use plain lidocaine 2% without epinephrine, or better yet, omit lidocaine entirely and use bacteriostatic normal saline to minimize injection pain.
The Evidence Against Lidocaine with Epinephrine
The most recent and highest-quality evidence directly addressing this question comes from a 2022 double-blind randomized controlled trial that found corticosteroid injections mixed with lidocaine and epinephrine were significantly MORE painful than those mixed with bacteriostatic saline (VAS pain score 5.0 vs 2.0, p=0.0056) 1. This counterintuitive finding has been confirmed by additional 2024 studies examining trigger finger injections 2.
Why Plain Lidocaine is Preferred Over Lidocaine with Epinephrine
When local anesthetic is used with steroid injections, plain lidocaine offers several advantages:
- Reduced injection volume: Epinephrine adds unnecessary volume to an already painful injection
- Lower acidity: Lidocaine with epinephrine has a lower pH, which increases injection pain
- Fewer pharmacologic risks: Eliminating epinephrine removes potential adverse reactions (tachycardia, anxiety, palpitations) in sensitive patients
- No vasoconstriction needed: Unlike surgical procedures where hemostasis matters, steroid injections don't benefit from the vasoconstriction that epinephrine provides
The Case for Omitting Lidocaine Entirely
Recent evidence suggests the optimal approach may be to skip lidocaine altogether:
- A 2024 Bayesian trial found that while lidocaine does reduce pain during injection by 2.4 points on the 0-10 scale 3, the 2022 trial showed that bacteriostatic saline produces even less pain than lidocaine with epinephrine 1
- The immediate analgesic benefit of lidocaine during injection must be weighed against the increased total injection volume and acidity
- For brief procedures like steroid injections, the anesthetic effect of lidocaine may be unnecessary
Clinical Algorithm
For routine steroid injections:
- First choice: Mix corticosteroid with bacteriostatic normal saline (lowest pain)
- Second choice: Mix with plain lidocaine 2% without epinephrine (if patient anxiety about pain is high)
- Avoid: Lidocaine with epinephrine (highest pain, unnecessary medication)
Important Caveats
The dermatologic surgery guidelines extensively discuss epinephrine use, but these apply to surgical procedures requiring hemostasis, not therapeutic steroid injections 4. While epinephrine is safe for use on digits, nose, and ears during surgery (refuting old dogma about terminal vessel necrosis), this safety profile is irrelevant for steroid injections where vasoconstriction provides no benefit.
Maximum dosing if you do use plain lidocaine: 4.5 mg/kg without epinephrine (versus 7.0 mg/kg with epinephrine) 4, 5. For a 70 kg adult, this equals 315 mg or approximately 15 mL of 2% lidocaine—far more than needed for typical steroid injections.
Bottom Line
The evidence clearly favors either bacteriostatic saline or plain lidocaine 2% over lidocaine with epinephrine for steroid injections, with emerging data suggesting saline may be optimal for minimizing patient discomfort 1.