Contraindications for Lidocaine Patch
The lidocaine 5% patch is contraindicated in advanced liver failure due to decreased lidocaine clearance, and should not be applied to broken or inflamed skin, with known hypersensitivity to amide anesthetics representing an absolute contraindication. 1, 2
Absolute Contraindications
- Advanced liver failure/hepatic dysfunction: Hepatic impairment reduces lidocaine clearance by approximately 60%, creating risk of systemic toxicity even with topical application 1, 3
- Application to broken or inflamed skin: This dramatically increases systemic absorption and risk of toxicity 2, 4, 3
- Known hypersensitivity to amide-type local anesthetics: Delayed-type (Type IV) hypersensitivity reactions can occur, though they are uncommon 2, 3, 5, 6
Relative Contraindications and Special Precautions
Cardiac Disease
While the evidence primarily addresses intravenous lidocaine, clinicians should exercise caution in patients with significant cardiac disease, as systemic absorption can theoretically cause cardiac arrhythmias and myocardial depression 1
Renal Impairment
No dose adjustment is required for renal impairment with lidocaine patches because systemic absorption is minimal, unlike systemic medications such as gabapentin or pregabalin 2, 3. However, severe renal failure can affect lidocaine metabolism when systemic levels are achieved, though this is not clinically relevant with proper topical patch use 7
Geriatric Patients
Elderly patients (>70 years) are at higher risk of lidocaine toxicity with systemic administration 1, 8, but the lidocaine patch remains safe in elderly patients due to minimal systemic absorption and requires no dose adjustment 1, 4
Hepatic Impairment
Beyond advanced liver failure (absolute contraindication), patients with moderate hepatic insufficiency should be monitored more carefully, though the minimal systemic absorption from patches makes toxicity unlikely with proper use 1, 2
Critical Safety Parameters
Dosing Limitations
- Maximum of 3-4 patches applied simultaneously for 12 hours daily, followed by a mandatory 12-hour patch-free interval 2, 3
- Pharmacokinetic studies confirm systemic lidocaine levels remain within safe range with up to four patches in 24 hours 1
Timing Restrictions with Other Local Anesthetics
Lidocaine patches must not be used within 4 hours of other local anesthetic interventions (nerve blocks, fascial plane blocks, infiltration) to prevent cumulative toxicity 1, 2, 3
Heat Application
Avoid excessive heat application over patch areas, as this increases systemic absorption and risk of toxicity 2, 4, 3
Monitoring for Systemic Toxicity
Although rare with proper topical use, monitor for signs of systemic absorption including 2, 4, 3:
- Dizziness and confusion
- Drowsiness or altered consciousness
- Bradycardia
- Muscle twitching
- Perioral numbness
Common Pitfalls to Avoid
- Do not confuse adverse reactions with true allergy: Many patients labeled as "lidocaine allergic" actually experienced vasovagal reactions or epinephrine-related symptoms from dental procedures, not true hypersensitivity 5
- Do not use patches for wound care: Despite off-label use, manufacturers explicitly warn against application to open wounds 1
- Do not assume pacemakers are a contraindication: This is not supported by evidence for topical patches, though it may be relevant for intravenous lidocaine 1
Skin Reactions
Adverse reactions are rare, mild, and mostly limited to local skin rash or irritation at the application site 1. Periodic skin checks should be performed for irritation or sensitization 2