What are the recommended anesthetic preparations and techniques for dermatologic procedures in pediatric patients?

Anesthetic Preparation and Techniques for Dermatologic Procedures in Pediatric Patients

Topical anesthesia should be used as a first-line method for minor dermatologic procedures in children, with combination approaches for more extensive procedures to avoid sedation or general anesthesia whenever possible. 1

Topical Anesthesia in Pediatric Dermatologic Procedures

Recommendations for Use

• Topical agents are recommended as first-line anesthesia for repair of dermal lacerations and other minor dermatologic procedures including curettage in children (Strength of recommendation: A; Level of evidence: I, II) 1
• Non-cocaine formulations are preferred over cocaine formulations for all office-based procedures (Strength of recommendation: A; Level of evidence: II) 1
• For skin biopsy, excision, or cases where topical agents alone are insufficient, adjunctive use of topical anesthesia should be considered to minimize discomfort of infiltrative anesthesia (Strength of recommendation: C; Level of evidence: III) 1
• For more extensive surgery, the combination of topical and infiltration anesthesia should be considered as an alternative to sedation or general anesthesia 1

Application Techniques

• Apply a thick layer of topical anesthetic cream to intact skin and cover with an occlusive dressing 2
• For minor procedures, application time should be at least 1 hour before the procedure 2
• For more painful procedures, application time should be at least 2 hours 2
• Dosing must be calculated based on the child's age and weight to prevent toxicity 2, 3

Maximum Recommended Doses by Age and Weight

• 0 up to 3 months or < 5 kg: 1 g over 10 cm² for 1 hour maximum 2
• 3 up to 12 months and > 5 kg: 2 g over 20 cm² for 4 hours maximum 2
• 1 to 6 years and > 10 kg: 10 g over 100 cm² for 4 hours maximum 2
• 7 to 12 years and > 20 kg: 20 g over 200 cm² for 4 hours maximum 2

Special Considerations

• Lidocaine iontophoresis (delivering lidocaine via electric current) is an effective method of topical anesthesia for pediatric dermatologic procedures with significantly reduced pain compared to placebo 4
• Careful observation is necessary to prevent accidental ingestion of topical anesthetics or disruption of the occlusive dressing 2
• A secondary protective covering may be useful to prevent inadvertent disruption of the application site 2
• Topical anesthetics should not be used in neonates with gestational age less than 37 weeks or infants under 12 months receiving methemoglobin-inducing agents 2

Local Infiltration Anesthesia in Pediatric Dermatology

Recommendations for Use

• For children, the maximum recommended dose is 1.5-2.0 mg/kg of lidocaine and 3.0-4.5 mg/kg of lidocaine with epinephrine (Strength of recommendation: C; Level of evidence: III) 1
• When infiltration anesthesia is necessary, adjunctive use of topical anesthesia beforehand is recommended to reduce the pain of injection 1

Safety Measures to Decrease Risk of Local Anesthetic Systemic Toxicity

• Use the lowest effective dose of local anesthetic 1
• Aspirate the needle prior to each injection to avoid introducing the drug directly into a vessel 1
• Use incremental injections of anesthetic 1
• Continually assess and communicate with the patient to monitor for signs of early toxicity 1

Combination Approaches for More Complex Procedures

• For more extensive surgery, combining topical and infiltration anesthesia can be an effective alternative to sedation or general anesthesia in select pediatric patients 1
• For procedures like full-face ablative laser resurfacing, a combination of topical, infiltrative, and nerve block anesthesia may be appropriate 1
• The combination approach can help reduce the total dose of infiltration anesthesia needed 1

Common Pitfalls and Caveats

• Calculating maximum doses based on weight is critical in pediatric patients to prevent toxicity 2, 3
• General anesthesia should be used with caution in children under one year of age due to potential long-term neurological side effects 3, 5
• Careful monitoring for signs of lidocaine toxicity is essential, including dizziness, excessive sleepiness, or duskiness of face or lips 2, 3
• The pain of administering infiltration anesthesia, coupled with needle anxiety, can lead to significant distress in children - topical anesthesia before infiltration helps minimize this 1, 6
• Creating a reassuring environment is particularly important for pediatric patients undergoing dermatologic procedures 6, 7

Procedure-Specific Recommendations

• For nonablative laser treatments: Topical anesthesia as first-line method 1
• For skin biopsy and small excisions: Topical anesthesia alone may be sufficient; if not, use topical followed by infiltration 1
• For dermal lacerations: Topical anesthesia as first-line method 1
• For curettage procedures: Topical anesthesia as first-line method 1, 5
• For more extensive procedures: Combination of topical and infiltration anesthesia 1

By following these evidence-based recommendations for anesthetic preparation and techniques in pediatric dermatologic procedures, clinicians can minimize pain and anxiety while ensuring patient safety and procedure success.