BLT Numbing Cream
BLT numbing cream (benzocaine, lidocaine, tetracaine) is a triple action topical anesthetic that is made in compound pharmacies for use by clinicians who perform minimally invasive procedures on the face and sometimes other parts of the body.
BLT numbing cream is commonly used in procedures such as tattoo removal, hair removal, cannula insertion, veni-puncture, suturing, wound cleaning, injection administration, cosmetic and laser procedures, tattooing, etc. The ideal topical anesthetic can provide complete anesthesia following a simple pain-free application, not contain narcotics or controlled substances, and be safe to use. BLT Topical Creams are used in similar instances as TAC Topical Compounds, TL Topical compounds, and non-compounded topicals containing lidocaine, benzocaine, tetracaine and prilocaine.
Compounded BLT Numbing Cream Risks
BLT numbing creams are know for their strong positive effect. They are made in various concentrations ranging from 20%, 4%, 2% to 20%, 10%, 10% respectively, benzocaine, lidocaine, tetracaine. Many of the BLT numbing cream compounds are made in very high concentrations. These concentrations are well above what is required to appropriately numb the skin according to the United States Food and Drug Administration (US FDA). It is often typical, that in concentrations above 20%, 4%, 2% that the active pharmaceutical ingredients (API’s) do not stay in solution and therefore present a gritty cream. The grit is often the undissolved API’s that do not enter into the skin and therefore do not improve efficacy. BLT numbing creams that are gritty also open the risk for adverse events, such as grit causing corneal damage in the event it enters the eye. There is a recent 2016, case where this adverse event did, in fact, cause corneal damage.
Another risk associated with multi-use jars or tubes of BLT numbing cream is the risk of cross-contamination. When the container is used on multiple patients, often by multiple clinicians, there is an inherent risk that microbes of other contaminants may be passed on to other who are being treated using the same container. Compounded BLT numbing creams are supposed to be supplied on an individual patient basis, in accordance with US FDA policies. When one prescription is supplied based on order from the clinician, yet used on more than one patient, the clinician is exposed to medico-legal risks in the event of a FDA or State Health Department audit, such as in the case of an adverse event. Compounded BLT numbing cream has the reputation of being very effective. In a 2012, study using it in laser procedures, it was shown to be more effective than other competitive approved topical numbing creams, such as EMLA or LMX5.
BLT Cream for Cosmetic Procedures
Triple-anesthetic BLT topical compounds containing benzocaine, lidocaine, and tetracaine (BLT) have been reported to be effective when applied prior to laser procedures. Cosmetic Dermatology 2003 Apr;16(4):35-7
Anecdotally, BLT Topical compounds have a reputation for providing a high degree of efficacy when properly applied prior to a myriad of superficial cosmetic procedures. Benzocaine is known to produce a fairly rapid onset of action while lidocaine and tetracaine produce a medium to long duration of efficacy. When used appropriately on small surface areas, the reputation of BLT topical compounds are that they are generally, reasonably well tolerated and very effective.
Challenges procuring, storing and using this type of topical anesthetic include (among others):
- Regulatory compliance,
- short shelf life (45 days),
- lack of modular capability (all three in combination may not always be medically necessary),
- time to effective onset of action,
- dosing precision,
- product quality assurance and uniformity.
- when supplied in multi-use jars, risk of cross contamination
“Unicorn” BLT topical compounds (or other effective topical anesthetic), have an extended shelf life, be compliant when produced and supplied in bulk, have a rapid onset of action, both an adequate duration, a simple, painless method of administration and an effective method of API delivery into the skin while limiting systemic entry.
What safe and effective alternatives may serve to overcome some of the associated challenges, while still maintaining a combination of ease of set up and removal, efficacy, duration of efficacy and acceptable safety profiles? The “holy grail” of topical anesthetic agent(s) or device(s) will satisfy the needs while eliminating the challenges. The question then will be, is it possible for one agent or modality to provide all or most of these attributes, or will it require a combination of two or more? At present, it seems that properly formulated BLT topical compounds satisfy the needs for more aggressive, pain causing procedures, while some of the other effective alternatives satisfy needs for less aggressive and ablative procedures that also cause varied degrees of pain.