What do dermatologists use to numb skin? A guide to local anesthetics

October 9, 2025 •

4 min read

Over 54 million outpatient dermatological procedures are performed annually, and for patient comfort during these treatments, dermatologists use a variety of methods to numb skin, including potent topical agents and targeted injections. Understanding what do dermatologists use to numb skin is key to feeling at ease before your next procedure.

Quick Summary

Dermatologists employ local anesthetics, such as lidocaine in topical creams and injectable solutions, to ensure patient comfort for procedures like biopsies, laser treatments, and surgery. The specific numbing method is chosen based on the procedure's invasiveness and location. Safety precautions are always a priority to prevent side effects.

Key Points

Topical vs. Injectable: Dermatologists choose between topical creams (like EMLA) for superficial numbing and injectable solutions (like lidocaine) for deeper anesthesia.
Lidocaine is Standard: Lidocaine is the most widely used local anesthetic in dermatology, available in both topical and injectable forms.
Epinephrine Enhances Injectables: Epinephrine is often added to injectable lidocaine to prolong the numbing effect and minimize bleeding.
Compounded Creams Offer Higher Potency: Custom-made creams, such as BLT (benzocaine-lidocaine-tetracaine), can provide stronger topical numbing but require careful use due to absorption risks.
Multiple Techniques Exist: Numbing methods include topical application, local infiltration, and nerve blocks, chosen based on the procedure type and location.
Safety Precautions are Crucial: Proper dosage, controlled application areas, and patient health history are considered to prevent systemic toxicity and allergic reactions.

The process of numbing the skin for a dermatological procedure is a science focused on patient comfort and safety. Local anesthetics work by temporarily blocking the sodium channels in nerve fibers, which prevents the transmission of pain signals to the brain. The choice of anesthetic and administration method depends on the procedure's depth, duration, and the patient's individual needs.

Topical Anesthetics: Creams and Gels

Topical anesthetics are applied directly to the surface of the skin and are a popular option for cosmetic procedures and minor surgical interventions. Their main advantage is pain relief without requiring injections, which is ideal for patients with needle phobia. The efficacy of a topical agent depends on its ability to penetrate the skin, which can be enhanced by covering the area with an occlusive dressing.

Common Topical Agents

EMLA Cream (Lidocaine/Prilocaine): A eutectic mixture of local anesthetics, EMLA is a prescription cream containing 2.5% lidocaine and 2.5% prilocaine. It is applied under an occlusive dressing for up to two hours to achieve a numbing depth of several millimeters.
Lidocaine Creams: Prescription-strength lidocaine creams, such as 5% formulations, are widely used. Over-the-counter versions with lower concentrations (e.g., 4%) are also available. Liposomal lidocaine is a newer formulation designed for faster and deeper penetration.
Compounded Formulations: Some dermatologists use custom-made topical creams mixed by compounding pharmacies. A common example is BLT cream, which contains benzocaine, lidocaine, and tetracaine in higher concentrations than standard products. While effective, compounded products lack the standardization of FDA-approved alternatives, and their use requires caution due to a higher risk of systemic absorption and toxicity.

Injectable Anesthetics: For Deeper Numbing

For more invasive procedures like skin biopsies, excisions, or Mohs surgery, an injectable anesthetic is necessary to numb the deeper layers of the skin. This method provides more rapid and profound anesthesia than topical creams.

Standard Injectable Agents

Lidocaine with Epinephrine: The most common injectable anesthetic in dermatology is lidocaine, often combined with epinephrine. The addition of epinephrine, a vasoconstrictor, reduces blood flow to the area, which both minimizes bleeding during the procedure and prolongs the anesthetic effect.
Buffering Lidocaine: The pain associated with an anesthetic injection is partly due to the acidic pH of the lidocaine solution. To minimize this stinging sensation, dermatologists may buffer the lidocaine by adding sodium bicarbonate just before injection.

Injection Techniques

Local Infiltration: The anesthetic is injected directly into the tissue surrounding the surgical site.
Field or Ring Block: The anesthetic is injected circumferentially around the area to be treated, blocking the nerves that supply the region. This prevents distortion of the tissue, which is important for cosmetic procedures.
Regional Nerve Blockade: For procedures on the face, hands, or feet, a nerve block can be used to anesthetize a larger area by targeting the main nerve supply.

Other Numbing Modalities

In addition to pharmacological agents, dermatologists may use other methods to reduce pain:

Mechanical Cooling: Applying ice packs or cold compresses to the skin for 15-20 minutes before a procedure can temporarily dull sensation. Cryosprays can also be used.
Vibration Devices: These devices can distract the nerves from the pain of an injection by overwhelming the sensory signals with a different sensation.

A Comparison of Common Anesthetic Methods


Method	Anesthetic Agents	Common Procedures	Speed of Onset	Duration	Pros	Cons
Topical Creams	Lidocaine, Prilocaine, Benzocaine, Tetracaine, EMLA, BLT creams	Minor injections, laser treatments, microneedling	30–60 minutes	1–3 hours	Avoids needles, good for minor procedures	Slower onset, less potent, limited depth
Injectable Infiltration	Lidocaine (with or without epinephrine)	Biopsies, excisions, Mohs surgery	Immediate (seconds to minutes)	1–4 hours (longer with epinephrine)	Rapid and profound anesthesia, greater depth	Needle discomfort, potential for bruising/swelling
Regional Nerve Block	Lidocaine, Bupivacaine	Facial fillers, nail procedures	Varies based on nerve targeted	Longer than infiltration (hours)	Minimal tissue distortion, less anesthetic volume needed	Requires anatomical expertise, takes longer to set up

Safety and Side Effects

Using numbing agents requires careful consideration to minimize risk. Systemic absorption of topical anesthetics is a major concern, particularly when applied over large surface areas or to compromised skin. High levels of lidocaine in the bloodstream can cause central nervous system (CNS) and cardiovascular toxicity, leading to symptoms like lightheadedness, ringing in the ears, or, in severe cases, seizures and heart problems.

Adverse Reactions

Methemoglobinemia: A rare but serious blood disorder associated with prilocaine (and high doses of other local anesthetics) where red blood cells are unable to deliver oxygen effectively.
Allergic Reactions: While uncommon, allergic reactions can occur, with contact dermatitis being a possibility.

Conclusion

From topical numbing creams for cosmetic enhancements to targeted injectable blocks for surgical procedures, dermatologists have a range of options to ensure patient comfort. Lidocaine, used in both topical and injectable forms, is the cornerstone of local anesthesia in dermatology. The best approach is always a personalized one, taking into account the procedure's specific requirements, the patient's medical history, and overall pain tolerance. Open communication with your dermatologist is essential to decide on the most appropriate numbing method for your procedure.

For a more detailed discussion on the use of topical lidocaine, consult this review from the Journal of Drugs in Dermatology:

Use of Topical Lidocaine for Cosmetic Dermatologic Procedures

Frequently Asked Questions

The most common numbing agent used by dermatologists is lidocaine, which is available in both topical creams and injectable solutions.

Topical numbing creams work by delivering anesthetic agents to the nerve endings in the upper layers of the skin, blocking the pain signals before they can be sent to the brain.

Injectable numbing agents are used for more invasive procedures, such as skin biopsies, excisions, and Mohs surgery, where a deeper and more profound numbing effect is required.

Epinephrine is added to injectable anesthetics to constrict blood vessels, which prolongs the numbing effect and minimizes bleeding at the procedure site.

Yes, risks exist, particularly with high-concentration or compounded creams applied to large areas. Excessive systemic absorption can lead to toxicity, with symptoms including dizziness, confusion, and heart problems.

You should always consult your dermatologist before using any over-the-counter numbing cream. They may advise against it or recommend a specific product to ensure it is appropriate and safe for your procedure.

Dermatologists use several techniques to minimize injection pain, including buffering the anesthetic with sodium bicarbonate to reduce acidity and using very fine-gauge needles.

EMLA is a topical cream containing a eutectic mixture of lidocaine and prilocaine. It is used to numb the skin before minor procedures, like injections, laser treatments, or minor surgeries.

Non-medicated alternatives include mechanical cooling methods, such as applying ice packs, or using vibration devices to distract the patient from the pain signal.