Emla Cream

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Emla Cream is a topical local anaesthetic containing a eutectic mixture of lidocaine 2.5% and prilocaine 2.5%.

Originally developed by AstraZeneca (now marketed by Aspen Pharma in the UK), Emla is one of the most widely used topical anaesthetics in clinical practice worldwide.

It is licensed for the production of surface anaesthesia of the skin before needle insertion (venepuncture, cannulation, vaccination), minor surgical procedures (curettage, cryotherapy, shave biopsy, cauterisation), and genital mucosal procedures.

It is also used on leg ulcers before debridement. Emla is available in the UK as a 5 g tube (pharmacy medicine) and in larger packs on prescription.

Pain associated with medical procedures is a significant cause of anxiety and distress, particularly in children, needle-phobic patients, and those requiring repeated interventions.

Effective topical anaesthesia can transform the patient experience, improving compliance with necessary procedures and reducing psychological trauma.

Emla was the first cream to demonstrate reliable anaesthesia of intact skin and has been used in clinical practice for over 30 years with an established safety profile.

This page provides a comprehensive clinical overview of Emla Cream, including how it works, correct application technique, dosing for different procedures and age groups, side effects, safety warnings, and how to obtain it in the UK.

Important safety information about Emla Cream

Before reading further, note the following essential safety points about Emla.

• Apply Emla at least 60 minutes before the procedure on intact skin. Shorter application times may result in inadequate anaesthesia.
• Do not exceed the recommended dose or application area, particularly in infants and young children, as excessive absorption may cause methaemoglobinaemia or local anaesthetic toxicity.
• Do not apply Emla to broken skin (except leg ulcers under medical supervision), near the eyes, or in the ear canal.
• Watch for blue-grey discolouration of the skin or lips after application, especially in young infants, which may indicate methaemoglobinaemia requiring urgent medical attention.

Understanding topical local anaesthesia

Local anaesthetics are drugs that reversibly block the transmission of nerve impulses in the region where they are applied or injected, producing numbness and pain relief without loss of consciousness.

They act by blocking voltage-gated sodium channels in the membranes of sensory nerve fibres, preventing the depolarisation and propagation of action potentials that carry pain signals to the brain.

Traditionally, local anaesthetics were administered by injection to achieve skin anaesthesia, which itself is a painful process.

The development of topical formulations that can penetrate intact skin represented a major advance in pain management, particularly for procedural pain in children and anxious patients.

However, intact skin presents a formidable barrier to drug penetration, primarily due to the stratum corneum (the outermost layer of the epidermis), which is composed of tightly packed, lipid-rich dead keratinocytes.

Conventional aqueous local anaesthetic solutions cannot penetrate this barrier in sufficient concentration to produce reliable anaesthesia.

The eutectic innovation

Emla overcomes the skin barrier challenge through its unique eutectic formulation.

Lidocaine has a melting point of 68 degrees Celsius and prilocaine has a melting point of 37 degrees Celsius.

When combined in a 1:1 ratio by weight, the resulting mixture has a melting point of 18 degrees Celsius, forming an oil at room temperature.

This oil is emulsified in water to create the Emla cream.

The high concentration of local anaesthetic in the oil droplets (80% base form) creates a steep concentration gradient across the stratum corneum, driving penetration of both drugs into the dermis where they reach the sensory nerve endings.

Under an occlusive dressing, hydration of the stratum corneum further enhances penetration.

How Emla Cream works: mechanism of action

Lidocaine and prilocaine are both amide-type local anaesthetics.

They exert their analgesic effect by reversibly blocking voltage-gated sodium channels (Nav channels) in the cell membranes of sensory nerve fibres.

Sodium channels are essential for the generation and propagation of action potentials.

When lidocaine or prilocaine binds to the intracellular portion of the sodium channel (primarily in the inactivated state), it prevents the influx of sodium ions needed for membrane depolarisation.

This blocks the initiation and conduction of nerve impulses along A-delta (sharp, fast pain) and C-fibre (dull, slow pain) sensory afferents.

The depth of anaesthesia achieved by Emla depends on the application time.

After 60 minutes under an occlusive dressing on intact skin, anaesthesia extends to a depth of approximately 3 mm. After 120 minutes, it may reach approximately 5 mm.

This is sufficient for most needle procedures and superficial dermatological interventions.

On genital mucosa, where the stratum corneum is thinner, adequate anaesthesia may be achieved in as little as 15 minutes.

After removal of the cream, the local anaesthetic effect persists for approximately 1 to 2 hours as the drug gradually diffuses away from the nerve endings and is absorbed systemically.

Lidocaine is metabolised by hepatic CYP1A2 and CYP3A4.

Prilocaine is metabolised by hepatic amidases to o-toluidine, which is an oxidising metabolite responsible for the methaemoglobinaemia risk associated with prilocaine.

Clinical evidence

Emla has been the subject of extensive clinical research since its introduction in the 1980s.

Randomised controlled trials have consistently demonstrated that Emla applied for 60 minutes under an occlusive dressing provides statistically and clinically significant pain reduction during venepuncture, cannulation, vaccination, lumbar puncture, and minor skin surgery compared with placebo cream.

A Cochrane review of topical anaesthetics for needle-related procedural pain in children confirmed that lidocaine-prilocaine cream significantly reduces pain scores compared with placebo, with a number needed to treat (NNT) of approximately 3 for achieving at least 50% pain reduction.

Studies in adults undergoing dermatological procedures, including curettage, cryotherapy, shave excision, and punch biopsy, have shown that Emla reduces procedural pain and the need for supplementary injected local anaesthesia.

For genital procedures (including genital wart treatment and minor genital surgery), Emla applied for 15 to 60 minutes provides effective surface anaesthesia.

For leg ulcer debridement, clinical trials have demonstrated that Emla applied under an occlusive dressing for 30 to 60 minutes significantly reduces pain during the debridement procedure, improving patient tolerance and compliance with wound care.

Dosage and administration by indication

Adults and adolescents (12 years and over)

For venepuncture, cannulation, and vaccination, apply approximately 1 to 2 grams of Emla (roughly half a 5 g tube) to the target area.

Cover with the provided occlusive dressing or cling film. Leave in place for a minimum of 60 minutes and a maximum of 5 hours.

Remove the dressing, wipe away the cream, and perform the procedure within 15 to 30 minutes for optimal anaesthesia.

For dermatological procedures such as curettage, cryotherapy, shave biopsy, cauterisation, and laser treatment, apply 1 to 2 grams per 10 cm2 of skin under an occlusive dressing for 60 to 120 minutes, depending on the depth of anaesthesia required.

For deeper procedures, a longer application time provides greater depth of numbness.

For genital skin procedures, apply 1 to 2 grams and cover with an occlusive dressing for 60 minutes on keratinised skin.

On genital mucosa, 15 minutes may be sufficient due to the thinner epithelial barrier. Do not apply to open wounds or ulcerated genital lesions.

For leg ulcer debridement, apply up to 10 grams (maximum) on a maximum area of 100 cm2 under an occlusive dressing for 30 to 60 minutes.

Treatment may be repeated at intervals of not less than 24 hours. Do not exceed 10 consecutive treatment sessions.

Paediatric dosing

The dose and application area for children are determined by age and body weight to minimise the risk of systemic toxicity and methaemoglobinaemia.

• Neonates (37 weeks gestational age and above) to 2 months: Maximum 1 gram on up to 10 cm2 for up to 1 hour. One application per 24 hours. Do not use on premature infants below 37 weeks gestational age.
• 3 to 11 months: Maximum 1 gram on up to 10 cm2 for up to 1 hour.
• 1 to 5 years: Maximum 2 grams on up to 20 cm2 for up to 1 hour (up to 5 hours for older children in this range at prescriber's discretion).
• 6 to 11 years: Maximum 2 grams on up to 20 cm2 for up to 1 hour (up to 5 hours at prescriber's discretion). For larger children, the prescriber may allow a greater dose and area.

Application technique

Squeeze the required amount of Emla onto the centre of the target area. Do not rub or spread the cream; leave it as a thick blob.

Place the occlusive dressing over the cream and seal the edges to prevent air reaching the skin. The occlusion hydrates the stratum corneum and enhances drug penetration.

Note the time of application. At the appropriate time, remove the dressing, wipe away the cream with a dry tissue, and perform the procedure promptly.

Side effects of Emla Cream

Common local side effects

The most common reactions are transient pallor (blanching) of the skin at the application site, followed by mild erythema (redness) after cream removal.

These reflect the successive vasoconstrictive and vasodilatory effects of prilocaine and lidocaine on dermal blood vessels and are entirely normal. Localised oedema (mild swelling) may also occur.

A transient burning, stinging, or tingling sensation during the first few minutes of application is common and indicates the onset of anaesthetic action.

Mild pruritus (itching) at the site is occasionally reported.

Uncommon side effects

Allergic contact dermatitis to lidocaine, prilocaine, or the cream base components may occur rarely, presenting as localised redness, swelling, vesicles, and itching that persist beyond the normal transient reaction.

Purpura (petechiae or small bruises) may appear at the application site after prolonged application times. Temporary numbness or altered sensation may persist for several hours after cream removal.

Rare systemic side effects

When Emla is used within the recommended dose and application area guidelines, systemic side effects are rare.

However, excessive application (large dose, large area, broken skin, or prolonged duration) may lead to systemic local anaesthetic toxicity.

Early symptoms include perioral numbness, metallic taste, light-headedness, dizziness, tinnitus (ringing in the ears), and drowsiness.

If absorption continues, more serious effects may develop, including visual disturbance, muscle twitching, tremor, convulsions, unconsciousness, and cardiovascular collapse (bradycardia, hypotension, cardiac arrest).

Methaemoglobinaemia, caused by the prilocaine metabolite o-toluidine, is the most important specific systemic risk.

At recommended adult doses, methaemoglobin levels typically rise by less than 1%, which is clinically insignificant.

In neonates, young infants, and patients with G6PD deficiency or congenital methaemoglobinaemia, the risk is higher.

Clinical signs include cyanosis (blue-grey discolouration of the lips, tongue, and skin), shortness of breath, headache, fatigue, and dizziness.

Severe methaemoglobinaemia (methaemoglobin levels above 30%) can cause seizures, coma, and death. Treatment is with intravenous methylene blue (methylthioninium chloride).

When to seek emergency help

Seek immediate medical attention by calling 999 if you or your child develop blue-grey discolouration of the lips or skin, confusion, drowsiness, difficulty breathing, palpitations, convulsions, or collapse after applying Emla.

These may be signs of methaemoglobinaemia or local anaesthetic toxicity requiring emergency treatment.

For milder concerns such as persistent redness, swelling, or blistering at the application site, contact your GP, pharmacist, or NHS 111.

Warnings and precautions

Methaemoglobinaemia risk

Prilocaine is metabolised to o-toluidine, which oxidises haemoglobin to methaemoglobin. At recommended doses in healthy adults and older children, the clinical significance is negligible.

However, the risk is increased in neonates and infants under 12 months (due to immature NADH-methaemoglobin reductase and higher proportion of fetal haemoglobin), patients with G6PD deficiency, patients with congenital methaemoglobinaemia, and patients concurrently taking other methaemoglobin-inducing drugs (including dapsone, sulphonamides, nitrofurantoin, phenytoin, and certain antimalarials).

In these groups, Emla should be used only when the benefit clearly outweighs the risk, at the minimum effective dose.

Do not exceed recommended doses

The risk of systemic toxicity is directly related to the total dose absorbed, which depends on the amount applied, the surface area treated, the integrity of the skin, and the application time.

Always adhere to the recommended dose, area, and duration limits for each age group.

In children, particular care is required as their lower body weight increases the relative dose exposure.

Avoid broken skin and sensitive areas

Emla must not be applied to cuts, grazes, open wounds (except leg ulcers under medical supervision), eczematous skin, or mucous membranes other than genital mucosa.

Absorption from damaged skin is unpredictable and potentially rapid, increasing the risk of systemic toxicity.

Do not apply near the eyes, as corneal anaesthesia may abolish the protective blink reflex.

Do not introduce into the ear canal, as contact with the middle ear may cause ototoxicity.

Patients with hepatic impairment

Both lidocaine and prilocaine are metabolised by the liver.

Patients with severe hepatic impairment have reduced clearance and may be at increased risk of systemic toxicity with repeated or high-dose use.

Lower doses and shorter application times should be used in this population.

Patients taking antiarrhythmic drugs

Lidocaine is a Class Ib antiarrhythmic agent. Patients receiving other Class III antiarrhythmic drugs (such as amiodarone) or other local anaesthetics should be monitored for additive cardiac effects if large doses of Emla are used.

How to obtain Emla in the UK

Emla 5 g tubes are classified as a pharmacy medicine (P) in the UK, meaning they can be purchased from a registered pharmacy without a prescription after consultation with the pharmacist.

Larger packs and the pre-medication pack (containing cream and occlusive dressings) may require a prescription.

Emla can also be prescribed by a GP, hospital clinician, or authorised online prescriber.

The standard NHS prescription charge in England is currently 9.90 pounds per item. Prescriptions are free for all patients in Scotland, Wales, and Northern Ireland.

For over-the-counter purchase, the price varies by pharmacy but a 5 g tube typically costs between 5 and 10 pounds.

Practical tips for using Emla

Apply Emla in good time before your appointment. Set a timer to remind you when the minimum application time has elapsed.

If attending a hospital or clinic for a blood test or cannulation, ask in advance whether you should apply Emla at home beforehand and how much time to allow.

For children, apply the cream at home before leaving for the appointment and cover with the occlusive dressing and a long-sleeved top to prevent the child from removing it.

Distraction techniques (such as videos, toys, or conversation) during the procedure can complement the anaesthetic effect and reduce anxiety.

If you are unsure where the needle will be inserted, ask a healthcare professional to mark the site in advance so that you can apply Emla to the correct area.

For blood tests, the inner elbow crease and the back of the hand are the most common sites; applying Emla to both areas increases the chance that the phlebotomist can use an anaesthetised site.

When to seek urgent medical advice

Seek immediate emergency help by calling 999 if you or your child develop blue-grey discolouration of the lips, tongue, or skin, unusual drowsiness or confusion, difficulty breathing, seizures, or collapse after using Emla Cream.

These symptoms may indicate methaemoglobinaemia or local anaesthetic systemic toxicity, both of which require urgent hospital treatment.

For non-emergency concerns (persistent skin irritation, rash, or prolonged numbness), contact your pharmacist, GP, or NHS 111.

Report any suspected adverse reactions via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Sources

• Emla Cream 5%, Summary of Product Characteristics (EMC)
• Prilocaine with lidocaine, British National Formulary (BNF)
• Lidocaine skin cream, NHS
• NICE CKS: Local anaesthesia
• MHRA Yellow Card Scheme