What are lidocaine patches used for?

Lidocaine Patches: Clinical Uses

Lidocaine patches are primarily indicated for localized neuropathic pain, with strongest evidence supporting their use as first-line therapy for postherpetic neuralgia, and additional applications for myofascial pain, cancer-related neuropathic pain, and various peripheral neuropathies. 1, 2, 3

Primary Indications

Postherpetic Neuralgia (First-Line Therapy)

• Lidocaine patches demonstrate exceptional efficacy for postherpetic neuralgia with a number needed to treat (NNT) of 2, making them one of the most effective treatments available for this condition. 1, 4
• Approximately 60% of patients achieve moderate to complete pain relief with proper 12-hour daily application. 4, 5
• Significant pain reduction occurs at all time points from 4-12 hours compared to placebo, with benefits appearing as early as Day 7 in 66% of patients. 6, 5
• Early application during acute herpes zoster neuralgia may prevent progression to chronic postherpetic neuralgia in up to 63% of cases. 7

Localized Neuropathic Pain Syndromes

• Effective for painful diabetic polyneuropathy, particularly for nighttime foot pain. 4
• Demonstrated efficacy in HIV-associated peripheral neuropathy. 4
• Recommended by the National Comprehensive Cancer Network for cancer-related neuropathic and myofascial pain, with stronger evidence than other topical agents. 3

Musculoskeletal Pain

• Indicated for myalgias, arthralgias, and myofascial pain as part of localized therapy approaches. 3
• Effective for back pain management, providing both immediate and sustained relief when combined with cream formulations. 2

Application Protocol

Dosing and Administration

• Apply up to 3-4 patches simultaneously to intact skin covering the painful area. 2, 3, 4
• Standard regimen: 12 hours on, 12 hours off (within a 24-hour period). 4
• Available in 4% over-the-counter concentration or 5% prescription strength. 2, 3
• Can be applied to dorsal or plantar surfaces of affected areas. 2, 4

Combination Approach

• Lidocaine cream can be applied to areas where patches may not adhere well or to complement patch coverage, providing immediate relief while patches deliver sustained medication. 2

Safety Profile and Monitoring

Systemic Absorption

• Minimal systemic absorption occurs even with four patches applied over 24 hours, with highest measured blood levels at only 0.1 micrograms/ml. 3, 6
• Pharmacokinetic studies confirm systemic lidocaine levels remain within safe range. 2, 3

Adverse Effects

• Adverse reactions are rare, mild, and mostly limited to local skin reactions (rash or irritation). 3, 8
• Application to the head is tolerated less well compared to trunk and extremities, with significantly more adverse events reported. 9

Contraindications

• Advanced liver failure (hepatic impairment reduces lidocaine clearance by 60%). 2
• Broken or inflamed skin. 2, 3, 4
• Known hypersensitivity to amide anesthetics. 2, 3, 4

Critical Precautions

• Avoid excessive heat application over patches, as this increases systemic absorption. 2, 3, 4
• Remove patches before starting intravenous lidocaine therapy. 2, 3
• Avoid using within 4 hours of other local anesthetic interventions. 2, 3
• Monitor for signs of systemic absorption: dizziness, confusion, bradycardia, drowsiness, disorientation, muscle twitching. 2, 3, 4

When Lidocaine Patches Provide Inadequate Relief

Combination Pharmacotherapy

• Add gabapentin starting at 50-100 mg three times daily, titrating to 900-3600 mg daily for neuropathic pain components. 3, 4
• Consider pregabalin 50 mg three times daily, titrated to 100 mg three times daily if gabapentin fails. 1, 4
• Tricyclic antidepressants (nortriptyline, desipramine) starting at 10-25 mg, titrated to 50-150 mg can be added. 4
• The combination of morphine and gabapentin should be considered for possible additive effects at lower individual doses. 1

Alternative Topical Agents

• Capsaicin 8% patch provides pain relief lasting up to 90 days from single application. 4
• Capsaicin 0.075% cream has an NNT of 3.26 for postherpetic neuralgia. 1
• Topical diclofenac gel (1%) may provide relief for bone metastases pain. 3, 4

Non-Pharmacological Therapies

• Combine with physical therapy or yoga for improved pain management. 2, 4

Common Pitfalls to Avoid

• Do not apply to broken or inflamed skin, as this dramatically increases systemic absorption and toxicity risk. 2, 3, 4
• Do not delay treatment in acute herpes zoster neuralgia—early application may prevent chronic postherpetic neuralgia development. 7
• Do not exceed 12 hours of continuous application to ensure adequate patch-free period and minimize skin irritation. 4
• Do not use in patients with advanced liver failure without careful monitoring, as lidocaine clearance is reduced by 60%. 2