What is the recommended dosing regimen for lidocaine (lidocaine) cream in managing neuropathic (nerve) pain?

Lidocaine Cream Dosing for Neuropathic Pain

For localized neuropathic pain, 5% lidocaine patches should be applied to the painful area for 12 hours per day, with a maximum of 3 patches used simultaneously, followed by a 12-hour patch-free period. 1, 2

Application Guidelines for Topical Lidocaine

• Apply 5% lidocaine patches directly to the painful area for up to 12 hours within a 24-hour period 1
• Maximum of 3 patches can be used simultaneously, depending on the size of the painful area 1, 2
• Ensure a 12-hour patch-free period between applications 1
• Patches can be applied to dorsal or plantar surfaces of the affected area 1
• Do not apply to broken or inflamed skin 1

Efficacy in Various Neuropathic Pain Conditions

• Topical lidocaine has demonstrated efficacy in multiple neuropathic pain conditions:
  • Postherpetic neuralgia 1, 3
  • Painful diabetic neuropathy 1, 4
  • HIV-associated peripheral neuropathy 1
  • Post-surgical neuropathic pain 5
  • Trigeminal neuropathic pain 5

Benefits of Topical Lidocaine

• Minimal systemic absorption, reducing risk of systemic side effects 2, 1
• Can be combined with other pain medications for multimodal analgesia 1
• Long-term efficacy has been demonstrated with sustained pain relief over years of treatment 6
• Well-tolerated with primarily mild local reactions at application sites 3

Safety Considerations

• Avoid excessive heat application over areas where lidocaine is applied, as it can increase systemic absorption 1
• Contraindicated in advanced liver failure and known hypersensitivity to amide anesthetics 1
• Monitor for signs of systemic absorption such as dizziness, confusion, and bradycardia 1
• Do not use topical lidocaine at the same time as, or within the period of action of other local anesthetic interventions 2

Alternative Formulations

• Lidocaine gel (5%) has also shown efficacy in patients with postherpetic neuralgia and allodynia and may be less expensive than patches 2
• For patients with inadequate pain relief from topical treatments, consider:
  • Gabapentin (starting dose 100-300 mg, titrated to 900-3600 mg daily) 2, 1
  • Pregabalin (starting dose 50 mg three times daily, titrated to 100-300 mg three times daily) 2, 1
  • Tricyclic antidepressants (e.g., nortriptyline, desipramine 10-25 mg starting dose, titrated to 50-150 mg) 2, 1

Important Clinical Considerations

• Topical lidocaine is most appropriate for well-localized neuropathic pain and is unlikely to benefit patients with central neuropathic pain 2
• Intravenous lidocaine has not shown significant long-term benefits for chronic peripheral neuropathic pain 7
• For patients with widespread pain or inadequate relief from topical treatments, systemic medications may be more appropriate 1

Common Pitfalls to Avoid

• Using more than 3 patches simultaneously, which may increase risk of systemic absorption 1, 2
• Applying patches for longer than 12 hours per day 1
• Failing to consider topical lidocaine as a first-line option for localized neuropathic pain due to its favorable safety profile 3
• Using intravenous lidocaine for long-term management, as evidence shows limited efficacy beyond short-term relief 7