EMLA Topical Cream: Application and Dosage Guidelines
Timing of Application
EMLA cream requires 60 minutes of application under occlusion to reach full effectiveness on intact skin. 1, 2 This extended application time is a critical consideration for procedural planning and represents the primary limitation of EMLA compared to newer alternatives.
- For procedures requiring deeper anesthesia (1-2 mm depth), the standard 60-minute application is adequate 3
- For deeper penetration (2-3 mm), extend application to 120 minutes 3
- For maximum depth anesthesia (up to 6 mm), apply for 3-4 hours under occlusion 3
- Application times shorter than 60 minutes (such as 20 minutes) have not demonstrated efficacy for procedures like IV cannulation 4
Approved Clinical Indications
EMLA is indicated for pain reduction during the following procedures on intact skin only:
- Intravenous line placement and venipuncture 1
- Lumbar puncture 1
- Vaccination (pretreatment 30-60 minutes before injection) 1
- Abscess drainage 1
- Joint aspiration 1
Important caveat: EMLA provides topical anesthesia for laceration repair, but this use is not FDA-approved 1, 2
Dosage Considerations
- Patients <12 months old or weighing <10 kg: Use reduced doses 1, 2
- Standard application: 0.5-2 g per site 5
- For IV placement: Apply to at least 2 sites over accessible veins to maximize procedural success 1, 2
Absolute Contraindications
Do not use EMLA in the following situations:
- Allergy to amide anesthetics 1, 2
- Non-intact skin (including open wounds, chronic wounds, or lacerations) 1, 6
- Recent sulfonamide antibiotic use (trimethoprim-sulfamethoxazole, erythromycin-sulfisoxazole) 1, 2
- Congenital or idiopathic methemoglobinemia 1, 2
- Infants <12 months receiving methemoglobin-inducing agents 1
- Emergent need for IV access (timing incompatible with required application duration) 1
Application Technique
- Apply cream to intact skin at the procedure site 1
- Cover with occlusive dressing to enhance penetration 1, 7
- Avoid mucous membrane contact or ingestion 1
- After 60 minutes (or appropriate duration), remove dressing and wipe skin clean before procedure 7
- Wash hands with soap and water after application 8
Critical Clinical Pitfalls
EMLA does not provide complete pain relief and should be discussed with patients/parents before application 1, 2. The American Academy of Pediatrics emphasizes that some patients may require procedures before EMLA reaches full effectiveness, necessitating backup pain management strategies 1.
Never apply EMLA to non-intact skin or chronic wounds due to risk of systemic absorption and local anesthetic toxicity 6. For open wounds requiring topical anesthesia, use LET (lidocaine-epinephrine-tetracaine) combinations instead, which provide anesthesia in 10-20 minutes 1, 2, 6.
Faster Alternatives When EMLA Timing Is Impractical
When the 60-minute wait is not feasible:
- Liposomal 4% lidocaine cream (LMX4): Effective in 30 minutes 1, 2
- Heat-activated lidocaine systems: Effective in 10-20 minutes 1, 2
- LET combinations (for open wounds): Effective in 10-20 minutes 1, 2, 6
- Intradermal lidocaine injection: Immediate effect when buffered with bicarbonate and warmed 1
Special Populations
Neonates: EMLA is safe and effective in full-term and preterm neonates for procedures such as circumcision and venipuncture when dosed appropriately (0.5-2 g) with application times of 60 minutes to 3 hours 5. Meta-analysis shows no significant difference in methemoglobin concentrations between EMLA-treated and placebo-treated neonates 5. However, EMLA has not demonstrated efficacy for heel lancing in neonates 5.
Home application: For scheduled outpatient procedures, parents can safely apply EMLA at home 60 minutes before arrival, reducing clinic waiting time 7.
Drug Interactions
Concurrent use of acetaminophen with EMLA should be approached cautiously, as both can cause methemoglobin formation 1. Consider ibuprofen or other non-aspirin analgesics as alternatives for post-procedure pain management 1.