Are there any issues with prescribing EMLA (lidocaine and prilocaine) cream for dressing changes on a chronic wound?

EMLA Cream for Chronic Wound Dressing Changes: Safety Considerations

EMLA cream should not be used on chronic wounds for dressing changes due to manufacturer warnings against application on non-intact skin and potential systemic absorption risks. 1

Safety Concerns

• EMLA cream is explicitly contraindicated for use on "cut, irritated or swollen skin" according to FDA labeling 1
• The manufacturer specifically warns against using EMLA on non-intact skin, which includes chronic wounds 1
• There are direct warnings by the manufacturer against its use in wound care despite off-label adoption 2
• Systemic absorption of lidocaine and prilocaine from open wounds poses potential risks, especially with repeated applications 1

Potential Alternatives for Pain Management During Dressing Changes

• Dressings should be selected primarily based on exudate control, comfort, and cost rather than incorporating topical anesthetics 2
• For chronic wounds, particularly diabetic foot ulcers, consider the following evidence-based dressing options:
  • Sucrose-octasulfate impregnated dressings for neuro-ischemic diabetic foot ulcers that are difficult to heal 2
  • Basic contact dressings or advanced dressings based on wound characteristics 2
• For pain management during dressing changes, consider:
  • Systemic analgesics administered prior to dressing changes 2
  • Lidocaine 5% patch may be used for neuropathic pain around the wound but not directly on the wound 2
  • Alternative topical anesthetics specifically formulated for open wounds, such as LET (lidocaine-epinephrine-tetracaine) combinations, which provide anesthesia in 10-20 minutes 3

Evidence on EMLA Use in Wound Care

• Limited research has examined EMLA use on chronic wounds with mixed findings:
  • A 2017 pilot study found that daily applications of EMLA as a primary dressing did not inhibit wound healing and may improve patient well-being, but larger studies are needed 4
  • Studies of EMLA on burn wounds showed plasma concentrations of lidocaine and prilocaine were below toxic thresholds, but this cannot be generalized to all chronic wounds 5
  • When applied to leg ulcers for 24 hours, peak plasma levels of lidocaine and prilocaine were observed 2-4 hours after application but remained below toxic thresholds 6

Clinical Recommendations

• Follow manufacturer warnings and avoid using EMLA on chronic wounds 1
• For diabetic foot ulcers, follow evidence-based guidelines that recommend dressings based on exudate control, comfort, and cost 2
• Do not use dressings containing antimicrobial agents with the sole aim of accelerating healing 2
• Consider alternative pain management strategies that do not involve applying topical anesthetics directly to the wound 2
• If topical anesthesia is absolutely necessary, consult with pain management specialists for safer alternatives specifically designed for use on open wounds 3

Common Pitfalls to Avoid

• Using EMLA on open wounds despite manufacturer warnings 1
• Applying occlusive dressings over wounds with EMLA, which can increase systemic absorption 1
• Failing to recognize signs of local anesthetic toxicity, which may include CNS symptoms such as dizziness, confusion, or seizures 2
• Assuming that because EMLA works well on intact skin, it is appropriate for chronic wounds 1