Q:

2/21/2013
A 25yo patient presented to me with history as a young child of developing facial swelling after application of sunscreen containing solarcaine (topical lidocaine) to the face. He recalls no other details. He tolerated stitches as a child (unknown age) but doesn't know what, if any, local anesthesia used. He also had general anesthesia around 8yo (believed to be after the solarcaine used) for tonsillectomy without complications. Again doesn't know what anesthesia used. He now requires wisdom tooth extraction and his oral surgeon prefers to use lidocaine (because it's longer acting than other locals) and would like testing/challenge with lidocaine prior to the procedure. Bupivicaine may be an option if unable to use lidocaine.

I am inclined to follow the protocol for testing/challenge to lidocaine. However, is it preferred to test/challenge (and recommend use by the surgeon if said challenge is negative) with a different anesthetic than the one to which is in question regarding a possible reaction?

A:

Thank you for your inquiry.

Normally, at least in my practice, one chooses a local anesthetic to which the patient has not reacted if possible. Part of the reasoning behind this is that it tends to increase the patient’s confidence that they will be able to tolerate the drug. On occasion, anxiety related to the testing procedure, can cause problems during the procedure, and anything one can do to mollify this is indicated. Therefore, in your case, I would recommend bupivacaine since you have said that it is an acceptable option. The testing/graded dosage challenge procedure is the same for all local anesthetics.

I would do this even though true allergic reactions to amide anesthetics are extremely rare. This brings up a parenthetic point which would not affect my choice of local anesthetics, but I mention only for the sake of interest.

As mentioned, true allergic reactions to amide local anesthetics such as lidocaine are extremely rare, whereas they are far more common to paraaminobenzoic acid preparations such as benzocaine. It is curious to note that, if one goes online, one can find Solarcaine products listed as containing benzocaine. For your interest, I have copied below a link to two of these websites (there are several). I assume it is feasible that the reaction your patient described could have been to one of these benzocaine-containing products if they were available to the family. This would of course make the whole issue a “straw man.”

Regardless, in the vast majority of instances, as I am sure you are aware, alternative amide local anesthetic agents can be safely tested and administered using the testing/graded dosage regimen you mentioned. I would not anticipate any problem with the bupivacaine.

Solarcaine Aerosol

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology