True Local Anesthetic Allergy Detected in 4.5% of Children

A recent study detected true local anesthetic allergy in 4.5% of children from a regional referral center at Hacettepe University in Türkiye.1

Allergic reactions to local anesthetic agents may occur due to sensitivity to either the ester or amide component, the methylparaben used as a preservative, or the antioxidants used in some formulations.2 The reaction may consist of cutaneous lesions, urticaria, or anaphylactoid reactions—all of which affect quality of life.

The incidence of allergic reaction to local anesthetics is reported at less than 1%.3 A 2013 study assessing local anesthetic hypersensitivity during 2000 and 2012 in 331 patients from the University Hospital Center in Rijeka, Croatia, found 419 independent adverse drug reactions during 346 procedures. Most patients reported only 1 adverse drug reaction, although 12.4% had 2 reactions, 4.2% had 3 reactions, 1.5% had 4 reactions, and 0.3 had 5 reactions. Local reactions occurred in 44 patients.

Limited data exists on the prevalence of local anesthetic allergy and diagnostic test results in children. Thus, investigators conducted a study to determine the prevalence of true local anesthetic allergy over 30 years using the clinical data and test results of patients with suspected immediate-type local anesthetic allergy.1

The study included 231 children with a median age of 9.1 years (range: 6.5 – 12.9 years) and 57.6% males. Most reactions occurred during dental procedures (84.8%), and the most frequent symptoms were mucocutaneous system reactions in 208 patients (90%). In total, 250 skin prick tests were conducted across all patients using the following drugs: articaine (n = 73; 29.2%), lidocaine (n = 71; 28.4%), prilocaine (n = 65; 26%), and mepivacaine (n = 40; 16%).1

Ten (4.3%) patients had a confirmed local anesthetic allergy with either a skin prick test (n = 1) or an intradermal test (n = 9).1 Among those testing positive, 8 children had 1 local anesthetic allergy, and 2 children had 2 local anesthetic allergies. The team observed that patients with a true local anesthetic allergy had a significantly lower median age (P = .004) and a greater rate of anaphylaxis (P < .001).

The multivariate analysis identified several potential risk factors for a true local anesthetic allergy, including symptoms of urticaria (odds ratio [OR], 21.724; 95% confidence interval [CI], 3.349 – 140.934; P = .001), a history of anaphylaxis (OR, 40.690; 95% CI, 5.877 – 281.747; P < .001), testing with articaine (OR, 34.559; 95% CI, 3.846 – 310.507; P = .002), and a family history of atopy (OR, 9.410; 95% CI,1.438 – 61.593; P = .019).1 Investigators noted that these findings should be interpreted with caution due to the small sample size.

“True LA allergy was detected in 4.3% of patients, slightly higher than reported in the literature,” wrote study investigator Melike Ocak, from Hacettepe University, and colleagues.1 “This may be due to our center being a regional referral center and the study population including immediate-type reactions. Despite the widespread use of LA, IgE-mediated allergy is less common than expected but not rare.”

Local anesthetic allergy can be detected via skin prick tests or intradermal tests. A retrospective review published earlier this year found that an intradermal test at a 1:10 dilution, followed by subcutaneous provocation, accurately diagnoses pediatric immediate-type local anesthetic allergy.4 This diagnostic strategy showed a high predictive value of 99% for patients with a history of anaphylaxis.

“A history compatible with anaphylaxis during [local anesthetic] use should first be tested with 1:100 and 1:1000 dilutions,” investigators of the review noted.4 “Additionally, articaine appears to be a suitable first‐choice agent for testing and clinical use.”

References

1. Ocak M, Bal Çetinkaya F, Akarsu A, et al. Thirty years' experience with immediate-type local anesthetic hypersensitivity reactions in children. Pediatr Allergy Immunol. 2025;36(8):e70178. doi:10.1111/pai.70178

2. https://www.clevelandclinicmeded.com/medicalpubs/pharmacy/JanFeb2001/allergicreaction.htm

3. Batinac T, Sotošek Tokmadžić V, Peharda V, Brajac I. Adverse reactions and alleged allergy to local anesthetics: analysis of 331 patients. J Dermatol. 2013;40(7):522-527. doi:10.1111/1346-8138.12168

4. Derman, C. New Protocol Accurately Diagnoses Pediatric Anesthetic Allergy. HCPLive. April 17, 2025. https://www.hcplive.com/view/new-protocol-accurately-diagnoses-pediatric-anesthetic-allergy. Accessed August 27, 2025.