Topical Pain Relief for Sterile Abscess
For sterile abscesses, topical lidocaine cream (5%) is the most appropriate option for pain relief, applied directly to intact skin overlying the abscess or to open wounds after drainage. 1
Primary Pain Management Strategy
The cornerstone of pain control for any abscess—sterile or otherwise—involves addressing the underlying fluid collection through incision and drainage when indicated. 2, 3 However, for pain relief specifically:
Topical Lidocaine Application
- Apply 5% lidocaine cream at a concentration of 1 mg/cm² to the affected area 4
- Liposomal topical lidocaine reaches full effectiveness in 30 minutes, while heated topical lidocaine works in 20 minutes 1
- For open wounds (post-drainage), topical anesthetic combinations like LET (lidocaine, epinephrine, and tetracaine) provide excellent anesthesia in 20-30 minutes 1
- Plasma levels remain safe even with application to areas up to 28% body surface area, with significant pain reduction lasting 4 hours without systemic side effects 4
Dosing Considerations
- Standard dose: 3 mL for patients >17 kg 1
- Pediatric dose: 0.175 mL/kg for patients <17 kg (based on maximum dose of 5 mg/kg lidocaine) 1
- Lower doses required for infants <12 months or weighing <10 kg 1
Supplementary Pain Control
When topical anesthetics provide inadequate relief:
- Add oral analgesics: paracetamol or ibuprofen (oral or parenteral) 1
- Consider perianal infiltration of local anesthetics for severe acute pain 1
- Buffered lidocaine with bicarbonate can be injected almost painlessly using slow injection with a small-gauge needle 1
Critical Contraindications
Do not use topical lidocaine if:
- Allergy to amide anesthetics exists 1
- Mucous membrane contact or ingestion risk is present 1
- Gross contamination of wound is present (for LET formulations) 1
Important Clinical Pearls
Application Technique
- Cover with an occlusive dressing after application to maximize absorption 1
- For open wounds, place cotton ball soaked with LET solution directly into the wound 1
- Allow to soak for 10-20 minutes or until wound edges appear blanched 1
Unexpected Benefit
- Topical anesthetic cream application may promote spontaneous abscess drainage in up to 24% of cases, potentially eliminating the need for procedural intervention 5
- When drainage is still required, prior topical anesthetic use reduces the need for procedural sedation from 41% to 24% 5
Alternative Agents (Less Effective)
- EMLA cream reaches full effectiveness in 60 minutes (slower than lidocaine formulations) and is not FDA-approved for wound anesthesia, though it can be used off-label 1
- Vapocoolant sprays are less effective in children due to intolerance of the cold sensation 1