Patients with suspected allergic reactions to local anesthetics should undergo allergy evaluation because most do not truly have allergy to these medications. There are case reports of anaphylaxis to local anesthetics in the literature but this is a very infrequent problem. Skin testing and subcutaneous challenge are performed to evaluate these reactions and also identify safe alternative local anesthetic agents. If testing with a local anesthetic is negative in the face of a convincing history, then one should investigate for other possible culprits. In the case of your patient, it is reasonable to perform skin testing in your office. This could be done for lidocaine (to further evaluation the possibility of an IgE-mediated reaction) but more importantly, the patient should be tested with an alternative, non-amide local anesthetic. If testing to a non-amide local anesthetic is negative, then incremental challenge should be performed to assess if it is tolerated. It may not be necessary to perform a lidocaine challenge, but if it were to be deemed necessary, then I agree with you that it would be best performed in a hospital setting.
I hope this information is helpful to you and your patient.
Jacqueline A. Pongracic, MD, FAAAAI