Leg ulcer progression caused by topical anesthesia with EMLA (TM) cream

While treating a 63-year-old woman with leg ulcerations, we observed an unusual phenomenon. A wound debridement was planned to remove adherent necrotic material. After topical anesthesia with a lidocaine-prilocaine mixture ( EMLA cream) a hemorrhagic, livid margin area developed around the ulcer 90 minutes after application. The area turned necrotic over days and the center was debrided. A more detailed history revealed that similar necrosis had occurred previously when EMLA cream had been employed. We interpreted the current event, as well as the past episodes, as a pathological reaction of the small cutaneous blood vessels to EMLA cream. The history also revealed an overlap connective tissue disease with microvascular impairment. After exposure to the topical anesthetics, the pre-damaged cutaneous blood vessels presumably produced a critical ischemia with subsequent necrosis. Based on this case, we recommend careful use of EMLA cream with frequent monitoring for necrosis when treating patients with a known disorder of microcirculation.