AbstractObjectiveCutaneous head and neck surgery can safely and effectively be performed using local anesthetic (LA). However, optimizing pain management during LA administration is paramount for patient comfort and procedural efficacy. The primary objective of this study was to investigate the comparative effectiveness of EMLA cream and ethyl chloride (EC) spray in mitigating pain associated with LA administration in cutaneous head and neck surgery.Study DesignRandomized controlled trial.SettingUniversity‐affiliated tertiary head and neck oncology center.MethodsSample size calculation was performed followed by computer randomization into the following groups: EMLA, EMLA placebo (aqueous cream), EC, and a control group (no topical agent). Demographics, pain, and procedural experience scores were recorded perioperatively. Statistical analysis was performed to analyse differences between groups utilizing the Mann‐Whitney U test, Kruskall‐Wallis test, Chi‐square test, and Spearman's Rho.Results121 cutaneous lesions with a median patient age of 76 were analyzed. There were no statistically significant differences in pain scores (median [IQR]) between patients receiving EMLA (4 [3.75]), EMLA placebo (4.8 [3.6]), EC (5.8 [2.8]), and no treatment (5 [4.1], P = .19). Procedural experience scores were clinically similar (P = .02). Risk factors associated with elevated nociceptive sensitivity were surgical site (scalp, P = .01), malignant lesions (P < .01) and lesion surface area (rs = 0.22, P = .01).ConclusionEMLA and EC did not mitigate LA‐associated pain in patients undergoing cutaneous head and neck surgery and as such practitioners should reconsider their use of these in this regard. Patients' operative experience remains excellent regardless of topical anesthetic use.Level of EvidenceIb.