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• W2017395764 abstract "Malignant or treatment-related skin lesions are common in the cancer population. The pain associated with these conditions may be related to local tissue injury, which may be complicated by infection, or to nerve injury. Pain may be difficult to treat. We describe the use of topical lidocaine in a vehicle of silver sulfadiazine cream, a topical antimicrobial agent,1Thornton Spann C. Taylor S.C. Weinberg J.M. Topical antimicrobial agents in dermatology.Clin Dermatol. 2003; 21: 70-77Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar in the management of these conditions. A 24-year-old man was referred for chemotherapy for stage IV nonseminoma with metastases in lymph nodes, lungs, liver, and brain. The right testicle was enlarged (12 cm). On the day of admission, bleeding in a cerebral metastasis necessitated cerebral metastectomy. After three days, chemotherapy was started (bleomycin, etoposide, and cisplatin). The right testicle and scrotum became painful due to swelling and the development of a decubitus of the overlying skin. He could not bear manipulation of the affected area. Acetaminophen was ineffective and nonsteroidal anti-inflammatory drugs were considered to be contraindicated because of the risk of renal impairment during treatment with cisplatin. Systemic opioids were avoided because of concern that their side effects might interfere with the follow-up of the intracerebral pathology. Treatment was initiated with lidocaine 5% in silver sulfadiazine cream. The cream was applied four times daily. After one day, he was able to sit and tolerated washing his scrotum. The lidocaine application was continued for six weeks. No side effects were observed. A 77-year-old woman with vulvar carcinoma was treated with radiochemotherapy (carboplatin and 5-fluorouracil). On Day 21 of the treatment, she developed painful vulvitis. The affected skin was erythematous and desquamated, leading to difficulties with sitting and voiding. Lidocaine 2% in silver sulfadiazine cream was started twice daily. At first, the symptoms were controlled. On Day 42 of treatment, acetaminophen (1 g three times daily) was added, and tramadol 50 mg twice daily was added eight days later because of worsening pain. With this regimen, the pain was satisfactorily controlled: she could sit and urinate without pain. A 66-year-old woman developed a painful vulvar carcinoma. Despite acetaminophen 1 g three times daily and morphine sulfate sustained release 20 mg in the morning and 40 mg in the evening, sitting and walking remained painful. The patient was treated with neoadjuvant radiochemotherapy (carboplatin and 5-fluorouracil). On Day 29 of treatment, the vulvar area showed edema with moist desquamation; the pain remained severe. Treatment with lidocaine 2% in silver sulfadiazine cream twice daily was started, while the oral dose of long-acting morphine sulfate remained unchanged. Within three days she was able to walk and sit on an ergonomic cushion with only modest pain. The cream could be stopped one week after the end of treatment. A 78-year-old woman with an anal carcinoma was treated with radiochemotherapy (5-fluorouracil and mitomycin). During the treatment, she developed vulvitis with erythema and desquamation. On Day 32, hospitalization was required for pain treatment. Pain control was inadequate despite acetaminophen and increasing doses of ibuprofen and transdermal fentanyl. Lidocaine 2% in silver sulfadiazine cream was applied twice daily. Two days thereafter, she could sit and walk, and only voiding remained painful. She continued to require additional opioid and developed constipation. The lidocaine concentration in the cream was increased to 5%, although the skin was still desquamated. The transdermal fentanyl dose could be reduced without worsening pain. Constipation improved. The serum lidocaine level, two hours after the first application of the 5% cream, was 1.7 mg/L (therapeutic range 1.5–5.0 mg/L). Two weeks later (17 days after the end of treatment), the skin was healing. The application of topical lidocaine in silver sulfadiazine was stopped and the transdermal fentanyl further decreased. A 43-year-old patient with vulvar carcinoma was treated with neoadjuvant radiochemotherapy (carboplatin and 5-fluorouracil) and developed vulvitis with erythema of the radiated skin on Day 11 of treatment. Despite acetaminophen and tramadol 50 mg twice daily, she could not sleep due to severe pain. Lidocaine 3% in silver sulfadiazine cream was administered twice daily. This was only moderately effective: she could sleep well, but voiding remained painful. Morphine sulfate sustained release 20 mg twice daily was started five days later and the dose was doubled after one week. After 25 doses (45 Gy), the radiotherapy was discontinued due to vulvar toxicity. Topical lidocaine in silver sulfadiazine cream alleviated pain due to cancer or treatment-related painful skin conditions. Neither systemic nor local side effects of the lidocaine in silver sulfadiazine were observed. A dose-effect relationship was suggested in one patient, as increasing the lidocaine concentration to 5% reduced the need for systemic therapy. In one case, pain could not be controlled with lidocaine 3% in silver sulfadiazine in combination with systemic pain therapy. It is possible that increasing the lidocaine dose might have been effective. The analgesic potential and the most effective dosing schedule of topical lidocaine in silver sulfadiazine cream remains to be investigated. Lidocaine is a local anesthetic with a low toxic potential.2Schug S.A. Cardwell H.M.D. Local anesthetics.in: Dukes M.N.G. Aronson J.K. Meyler's side effects of drugs. 14th ed. Elsevier, Amsterdam2000: 339-356Google Scholar However, toxic and hypersensitivity reactions can occur. Central nervous system toxicity is related to serum concentrations, with symptoms ranging from light-headedness and tinnitus to convulsions and coma. Cardiovascular depression only occurs at very high serum concentrations. In dogs, cardiovascular collapse was observed at a mean lidocaine serum level of 113.2 μg/mL (range 64.6–198.2 μg/mL).3Groban L. Deal D.D. Vernon J.C. James R.L. Butterworth J. Cardiac resuscitation after incremental overdosage with lidocaine, bupivacaine, levobupivacaine, and ropivacaine in anesthetized dogs.Anesth Analg. 2001; 92: 37-43Crossref PubMed Scopus (219) Google Scholar The lidocaine serum levels in one patient who received topical 5% lidocaine on disrupted skin remained 38-fold lower than these cardiovascular toxic levels. Lidocaine in silver sulfadiazine is contraindicated in sulfa allergy. As lidocaine is metabolized in the liver, caution also is warranted in compromised liver function and combined usage of drugs interacting with the CYP1A2 and CYP3A4 enzymes.4Marra D.E. Yip D. Fincher E.F. Moy R.L. Systemic toxicity from topically applied lidocaine in conjunction with fractional photothermolysis.Arch Dermatol. 2006; 142: 1024-1026Crossref PubMed Scopus (72) Google Scholar In conclusion, lidocaine 2% in silver sulfadiazine cream twice a day seems an effective local treatment for painful cancer or treatment-related skin lesions. This study was supported by the Integraal Kanker Centrum Noord Nederland (IKN)." @default.
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• W2017395764 title "Topical Lidocaine in Silver Sulfadiazine Cream on Painful, Cancer, or Treatment-Related Skin Lesions" @default.
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