Trick of the Trade:
Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D).
In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children.
- Retrospective chart review of children presented with skin abscess to an urban ED.
- Excluded are pilonidal abscess, paronychia or abscess involving genitalia.
- A subset of 300 patients were selected (100 at each of 3 academic sites).
- The treating physician decided whether a topical anesthetic should be used.
- The sites used a topical lidocaine cream (LMX 4). The cream is applied on the abscess with an occlusive dressing for 30-40 minutes. They looked at abscess treatment and return visits.
- 169 children required treatment in the ED.
- 110 received topical anesthetic (younger, more MRSA, less surrounding cellulitis) and 59 did not.
- Mean abscess size was not different between the two groups: 3.4 ± 2.4 with topical anesthetic vs 4.0 ± 2.7 cm without topical anesthetic, p = 0.22).
- 26/110 (24%) abscesses with topical anesthetic spontaneously drained in the ED vs 0/59 (0%) without a topical anesthetic.
- For the the topical anesthetic group, 26/110 (24%) needed procedural sedation. In contrast, 24/59 (41%) abscess without topical anesthetic needed procedural sedation. (OR 0.45)
- 22% in the topical anesthetic group returned to the ED (2% needed intervention) versus 34% in the no topical anesthetic group (none needed intervention).
How would this change my practice?
I would consider using topical anesthetic cream prior to abscess drainage. Even though it might still need I and D, I might avoid a procedure sedation.
Because this study was a retrospective study, selection bias may have occurred. Specifically, providers may have preferentially applied topical anesthetic or chosen procedural sedation, based on undocumented characteristics. It was nice to see that mean abscess size was not different between the two groups.
Cassidy-Smith T, Mistry RD, Russo CJ, McCans K, Brown N, Capano-Wehrle LM, Drago LA, Vitale PA, Baumann BM. Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children. Amer J Emerg Med. 2010 - in press. PMID: 21129885