AbscessDiagramAbscess drainage can be painful and time consuming in the ED. Can this article help? 1

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.

Study Design

  • 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).

Data collection

  • 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.
Action Topical anethestic (n=110) No topical anesthetic (n=59) % difference
Spontaneous abscess drainage 26 (24%) 0 (0%) 24%
Incision and drainage 107 (97%) 59 (100%) -3%
Procedural sedation 26 (24%) 24 (41%) -17%
Hospitalization 10 (9%) 9 (15%) -6%

Results

  • 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.

Study limitation

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.

1.
Cassidy-Smith T, Mistry R, Russo C, et al. Topical anesthetic cream is associated with spontaneous cutaneous abscess drainage in children. Am J Emerg Med. 2012;30(1):104-109. [PubMed]
Stella Yiu, MD

Stella Yiu, MD

ALiEM Blog Contributor
Assistant Professor, University of Ottawa Staff Physician, The Ottawa Hospital
Stella Yiu, MD

@Stella_Yiu

Emergency physician and clinician educator in Ottawa, Canada. Own opinions. Go #FOAMed!