Lidocaine Contact Allergy Is Becoming More Prevalent Derek To, BSc,* Irèn Kossintseva, MD, FRCPC, FAAD,† and Gillian de Gannes, MD, FRCPC, FAAD*†‡

BACKGROUND Allergic contact dermatitis (ACD) to lidocaine is rising in prevalence. This is due to a growing number of over-the-counter (OTC) products containing topical amide and ester anesthetics. The phenomenon poses a real threat to the authors’ surgical anesthetic options. OBJECTIVE To investigate the epidemiology of topical anesthetic ACD in British Columbia, Canada and provide an approach for clinicians to deal with this problem. MATERIALS AND METHODS A retrospective chart review of 1,819 patients who underwent patch testing at the University of British Columbia Contact Dermatitis Clinic between January 2009 and June 2013 was completed. The authors also performed a detailed review of Canadian OTC preparations containing lidocaine in 2013. RESULTS The prevalence of ACD to local anesthetics is significant at 2.4%. The most common allergen is benzocaine (45%) followed by lidocaine (32%) and dibucaine (23%). CONCLUSION The proportion of ACD caused by lidocaine is higher than expected. This is likely secondary to an increase in OTC medicaments containing lidocaine. Patients who are patch test–positive to a local anesthetic should be challenged intradermally to confirm clinical relevance. Because ACD is a delayed Type IV hypersensitivity reaction (localized dermatitis), the risk of anaphylaxis is not a concern. The authors have indicated no significant interest with commercial supporters.


llergic contact dermatitis (ACD) is a Type IV or delayed type hypersensitivity reaction that develops at the site of contact with an allergen.1 This presents as pruritic erythematous papules and vesicles that coalesce into edematous plaques and bullae.2 The lesions begin at the primary site of contact but may manifest at multiple distant sites (autoeczematization) with chronic exposure to an allergen.3 Anesthetics are divided into 2 classes: ester and amide compounds. Esters such as benzocaine tend to be used in topical over-the-counter (OTC) or in-office preparations. Amides such as lidocaine are the anesthetics of choice in local intradermal or nerve block pain management. Traditionally, the ACD prevalence of ester anesthetics significantly outnumbered that of the amides.4,5 This owed to the easy

sensitization from frequent, often unknowing topical ester exposure. Previous literature quotes the occurrence of a Type I (or anaphylactoid) hypersensitivity to amides as rare and much less frequent than Type IV hypersensitivity.6–10 Newer literature shows that ACD to many commonly used local anesthetics is not infrequent among patients presenting for patch testing.11 Data from multiple countries highlight the variability in anesthetic ACD as being a reflection of different types of sensitizers present in OTC products in different geographic locations (Table 1).12 The addition of amide to many topical OTC preparations may be a key factor in the increasing prevalence of lidocaine ACD.13–15 These can be found in a vast array of medicaments like hemorrhoidal preparations, oral ulcer care, athlete’s foot remedies,

*Faculty of Medicine, University of British Columbia, Vancouver, Canada; †Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada; ‡Division of Dermatology, Department of Medicine, St. Paul’s Hospital, Vancouver, Canada


© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:1367–1372 DOI: 10.1097/DSS.0000000000000190



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corn and callus treatments, and antibiotic ointments.9,11,14,16,17 The phenomenon is concerning not only in the isolated surgical population but also in the aging population at large. The elderly tend to be more frequent users of these highly sensitizing topical anesthetic preparations18–20 and require local anesthesia on a more frequent basis, such as for skin cancer surgeries21 or for other minimally invasive in-office procedures.22 These OTC products result in unnecessary exposure and create potential sensitization to a very clinically important class of medications. Therefore, the authors aimed to assess the epidemiology of ACD to local anesthetics.

Dermatitis Group 70 allergen series, to additional anesthetic allergens when supplied by the patient (presurgical or dental assessment), and to the patient’s own products when ACD to anesthetics was clinically suspected. Patch testing and data collection were performed as per Fransway and colleagues.23 Data collected from all patients with a positive patch test reaction to a topical anesthetic were used for analysis of the ACD prevalence, for characterization of the proportion of local anesthetic types associated with ACD, for clinical presentation of ACD to topical anesthetics, and for assessment of patient demographics.


A detailed review of OTC preparations containing lidocaine was performed by examining the ingredients found in all suspect products stocked in major chain pharmacies and those listed on the Health Canada Drugs and Products website (Table 1).

A retrospective chart review was performed on 1,819 patients who had undergone patch testing for suspected ACD at the University of British Columbia (UBC) Contact Dermatitis Clinic between January 2009 and June 2013. Patients are referred to the UBC Contact Dermatitis Clinic by dermatologists, allergists, and family physicians from British Columbia for comprehensive patch testing when there is a suspicion of ACD to either a personal product or an occupational allergen. This tertiary care clinic maintains an inventory of over 500 allergens and is the only dermatology center providing access to patch testing in the province of British Columbia. Patients were patch tested to the North American Contact

Results The overall prevalence of ACD to topical anesthetics was 2.4% after reviewing the charts of 1,819 patients who were referred to the UBC Contact Dermatitis Clinic for any type of ACD. Among the patients who developed ACD to local anesthetic, the female to male ratio was 1.6:1 (3.2% male vs. 1.9% female prevalence). Benzocaine had the highest prevalence at 1.1% followed by lidocaine (0.77%) and dibucaine

TABLE 1. Multi-Country Epidemiology of ACD to Local Anesthetics Overall Incidence of ACD to Anesthetics


ACD to Benzocaine

ACD to Lidocaine Proportion (%)



0.5% (1985–2010) 1% (1986, 2004, 2010)

0.3% (1994–2001) 0.14% (2007–2009)






Dibucaine (80)





Hong Kong26





3.4% (2001–2004)

1.7%–3.5% (1984–2001)

0.7% (2001–2002)

Benzocaine (44)


Lidocaine (8)

The United States27–29

2% (1996–1998) Canada

2.4% (2009–2013)



Dibucaine (32) N/A

Lidocaine (23) Benzocaine (45) Lidocaine (32) Dibucaine (23)

N/A, not applicable.



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(0.55%). With the prevalence known, the majority of ACD was found to be caused by benzocaine at 45.5%. Lidocaine and dibucaine each contributed to 31.8% and 22.7% of the cases of ACD, respectively. Of the patients with ACD to local anesthetics, 13.6% had a concomitant ACD to Polysporin Complete ointment (Johnson & Johnson, Guelph, Canada) that contains lidocaine (Table 2). Most frequently affected sites of ACD were the head, which accounted for 44% of the events, followed by the hands (30%), whereas the body and other extremities accounted for 26% and 12%, respectively (Table 2). Lidocaine was found to be an active ingredient in several OTC pain- or itch-relief lotions, creams, sprays, drops, and antibiotic preparations available in major Canadian pharmaceutical chain stores (Table 3).

Discussion The authors’ comprehensive data at their facility for patients who presented between 2009 and 2013 showed an overall prevalence of ACD to local and topical anesthetics at 2.4%. Although this figure is lower compared with some previous reports,4,31,32 it presents a significant problem. As expected, the face, trunk, and hands are the major sites of predilection for anesthetic ACD, consistent with previous studies.27,33,34 This is reflective of common locations of OTC sensitizer application, but also poses a concern because these same locations tend to be the sites

TABLE 2. Characteristics of ACD to Local Anesthetics in British Columbia, Canada ACD Prevalence Proportion of Local Site of (Overall 2.4%) Anesthetics Predilection (%) Causing ACD (%) (%) Benzocaine (1.1)

Benzocaine (45.5)

Head (44)*

Lidocaine (0.77)

Lidocaine (31.8)

Hands (30)

Dibucaine (0.55)

Dibucaine (22.7)

Body (26)

Carbocaine (3)

Extremities (12)

Carbocaine (0.07)

*Twenty-one percent occurred on the eyelids.

TABLE 3. Canadian OTC Products Containing Lidocaine30 Product


Aloe vera gel with lidocaine Bactine liquid first aid spray


Solarcaine first aid lotion


Band-Aid Hurt-Free antiseptic wash

Johnson & Johnson

Polysporin antibiotic and pain-relief ear drops

Johnson & Johnson

Polysporin Complete ointment

Johnson & Johnson

Antibiotic plus pain-relief cream for kids After sunburn-relief lidocaine continuous spray


After sun soothing spray

KINeSYS Pharmaceutical Inc.

After burn

Tender Corp.


Prime Enterprises, Inc.


Aleviar Pharma Corp.

Betacaine gel

Prollenium Medical Technologies, Inc.

Bikini zone

CCA Industries, Inc.

Caribbean breeze burn relief

Caribbean Breeze International, Inc.

Dr. Numb

Shinsachi Media Inc.

EMLA cream

AstraZeneca Canada Inc.

Hawaiian Tropic after sunburn relief

Energizer Canada Inc.

Soothing gel with lidocaine

Energizer Canada Inc.

Safetec Sting Relief

Safetec of America Inc.

Skin envy soothing cream

Farleyco Marketing Inc.

SmartShield Aftersun Stallion

SmartShield Sunscreens Lockerroom Marketing Ltd.

STUD 100

Pound International Ltd.

Topicaine 5

ESBA Laboratories, Inc.


Trans Research Labs Inc.

Water-Jel Burn-Jel 2%

ZEE Medical Inc.

X3 On-the-go first aid burn-relief spray PMS-Lidocaine Viscous 2%

X3 Labs Inc. Pharmascience Inc.


Dentsply Canada Ltd.

Maxilene 4/5

RGR Pharma Ltd.


Sandoz Canada Inc.

Lidomax 5

Vivier Canada Inc.

Lidodan Viscous 2%/Jelly 2%

Odan Laboratories Ltd.

Lidocaine hydrochloride solution

Prime Enterprises, Inc.

40:12:DECEMBER 2014


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most commonly requiring surgery under local anesthesia. Benzocaine proved to be the most common anesthetic allergen, comprising of 45.5% of the positive patch tests, as expected because of its ubiquitous presence in many OTC topical analgesic medicaments, and in keeping with previous reports of its highly antigenic metabolite, para-aminobenzoic acid (PABA).4,28,35 Warshaw and colleagues31 and Beck and Holden36 demonstrate similar results of benzocaine being the most common contact allergen, outnumbering the prevalence of dibucaine. In contrast, Sidhu and colleagues12 and Wilkinson and colleagues37 report British data that show the opposite prevalence with dibucaine being a more frequent ACD offender than benzocaine. The difference likely lies in the geographic variation of what anesthetic additive is more commonly found in OTC products of a given location. Hence, it is not surprising that a larger number of OTCs contain dibucaine in the United Kingdom, where these 2 studies were conducted.12 The most significant finding is the 0.77% prevalence of lidocaine ACD that this study reveals. Lidocaine comprised of a greater proportion of the reactions than anticipated, and this was greater than that of dibucaine (31.8% vs. 22.7%). This may be related to an increase in the OTC products containing lidocaine. Because there is no literature that can accurately quantify this increase, the authors have put together a list of common Canadian OTC products containing lidocaine (Table 3) that can be compared with the US data from more than 10 years ago.11 Lidocaine allergy is reflected in patients presenting to the UBC Contact Dermatitis Clinic for patch testing as a result of strong ACD reactions after minor procedures under local anesthesia or skin injury (Figures 1 and 2). These patients subsequently demonstrate positive patch test results to lidocaine (Figure 3). Furthermore, the problem is often exacerbated by the lidocaine-containing analgesic portion of postoperative antibiotic ointments. The authors observed a clinically significant 13.6% portion of patients who are allergic to Polysporin Complete ointment. Of those with an ACD to Polysporin Complete, none had


Figure 1. Delayed hypersensitivity reaction to lidocaine 4 days after a dental procedure.

a concomitant ACD to bacitracin or benzocaine. This finding provides strong support for avoidance of postoperative topical antibiotic ointments to minimize the risk of ACD to the various components in these ointments, some of which may include lidocaine. Patients who are patch test–positive to lidocaine will require further testing, because the possibility of cross-reactivity may also be an issue. Both mepivacaine and prilocaine have been shown to cosensitize to lidocaine.38–42 In this study, 2 patients developed ACD to both benzocaine and lidocaine. However, clear data to support or refute such cross-reactivity are lacking in the literature.11,43,44 Patients who are patch test–positive to local anesthetics should be challenged with an intradermal injection of 0.1-mL preservative-free 1% lidocaine with the rubber stopper removed. Not aspirating through the rubber stopper avoids false positive results in patients with sensitivities to rubber compounds.33,45 Solutions must be preservative-free because methylparaben is


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Preoperatively, all patients should be questioned to discern any known allergies including local anesthetics. If the history is suggestive of an ACD to local anesthetics, ideally the patient should be referred for patch testing and intradermal challenge. However, if the patient immediately undergoes presurgery and their history is suggestive of ACD to lidocaine, the surgeon can safely proceed with the procedure using a different local anesthetic. If the choice is to use lidocaine, the patient can be pretreated with systemic corticosteroids or instructed to use topical corticosteroids if dermatitis develops. Anaphylaxis is not a concern in patients with delayed Type IV hypersensitivity reactions to lidocaine. Conclusion

Figure 2. Vesicles and bullae developed 3 days after the application of Polysporin Complete ointment following a minor abrasion on the palm of the hand.

metabolized to PABA, another common potential sensitizer.46 This intradermal test will facilitate accurate assessment of true ACD to lidocaine.47 Other local anesthetics should also be tested to provide the patient with a list of safe alternatives.

Allergic contact dermatitis to topical lidocaine is on the rise. The increase can be attributed to a growing number of OTC products containing lidocaine and the aging population who frequently use these preparations. If ACD is suspected in the preoperative setting, then probing further into a patient’s previous or current use of high-risk OTC preparations is justified. Patients who are both patch test– and intradermal challenge–positive to lidocaine should be provided with a list of alternative local anesthetics that can be used. This list can be presented to their primary and specialist care providers for future reference. Thus, education of the patient regarding sensitization in these OTC products is key. References 1. Cashman MW, Reutemann PA, Ehrlich A. Contact dermatitis in the United States: epidemiology, economic impact, and workplace prevention. Dermatol Clin 2012;30:87–98, viii. 2. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: epidemiology, responsible allergens, and management. J Am Acad Dermatol 2008;58:1–21. 3. Davis MD. Unusual patterns in contact dermatitis: medicaments. Dermatol Clin 2009;27:289–97, vi. 4. Warshaw EM, Belsito DV, Taylor JS, Sasseville D, et al. North American contact dermatitis group patch test results: 2009 to 2010. Dermatitis 2013;24:50–9. 5. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg 2012;38:709–21. 6. Fuzier R, Lapeyre—Mestre M, Mertes PM, Nicolas JF, et al. Immediateand delayed-type allergic reactions to amide local anesthetics: clinical features and skin testing. Pharmacoepidemiol Drug Saf 2009;18:595– 601.

Figure 3. Day 3 (48-hour) positive patch test reaction (+++, bulla) to lidocaine hydrochloride 15% in petrolatum.

7. Ismail K, Simpson PJ. Anaphylactic shock following intravenous administration of lignocaine. Acta Anaesthesiol Scand 1997;41:1071–2.

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Address correspondence and reprint requests to: Derek To, c/o Gillian de Gannes, Department of Dermatology and Skin Science, The Skin Care Center, 835 West 10th Avenue, Vancouver, BC V5Z 4E8, Canada, or e-mail: [email protected]


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Lidocaine contact allergy is becoming more prevalent.

Allergic contact dermatitis (ACD) to lidocaine is rising in prevalence. This is due to a growing number of over-the-counter (OTC) products containing ...
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