NEW YORK—Several procedures in dermatology, such as excising lesions and injecting certain medications, can be distressing for patients due to anxiety and pain-related factors. Reducing a patient’s distress, whether they are an adult or child, benefits everyone, said Peter A. Lio, MD, in his presentation on pain management in dermatology at the 2019 American Academy of Dermatology Summer meeting. He presented with Alisa, McQueen, MD, on techniques for reducing patients’ experiences of pain, anxiety, and stress during a procedure.
Dr Lio’s interest in the topic started during his internship in pediatrics in Boston, where there was a tremendous emphasis on pain free procedures to reduce the risk of “ruining patients for life in terms of medicine.”
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In dermatology, the practice of reducing pain and discomfort during procedures is more variable. The value of lessening patients’ experiences of pain and discomfort benefits everyone, according to Dr Lio. Not only does it help lower pain and anxiety in patients, but the dermatologist has a smoother procedure and studies show procedure rates are better with patient comfort, he said.
Addressing Distress
Dr McQueen, who works in pediatric emergency medicine, outlined the components that contribute to distress during procedures, based on Amy Baxster’s work. Stress consists of the physical pain from the procedure, the fear and anticipation of the procedure, which is sometimes worse than the actual procedure, and attention to the experience. These combined factors cause distress, Dr McQueen said.
Using a combination of analgesic, anxiolytic, and distraction techniques can reduce stress and maximize patient comfort. Some analgesic options for infants include:
- Skin-to-skin contact. Studies showed infants who were allowed skin-to-skin contact during vaccinations or heal sticks cried and grimaced less and had an even heart rate throughout the procedure. Breastfeeding has similar effects.
- Sucrose. A sucker made from a sponge with sugar water has been found to calm infants. The effects of sucrose during painful procedures has been so rigorously studied that it has been suggested that sucrose no longer needs to be studied, said Dr McQueen. The recipe Dr McQueen gave was 10ccs of sterile water and 1 packet of sugar.
Stimulating the inhibitory fibers decreases the sensation of pain at the synapse’s point, Dr McQueen stated. Temperature change and sensory change, performed using a vibration tool, stimulate the fibers that inhibit impulses. “For injections, the mantra is to put it [the device] between the pain and the brain,” said Dr McQueen.
Anesthetics
Topical anesthetics are effective but probably underutilized, said Dr Lio. They stop the signal for a few minutes to hours and are very safe overall for reducing pain during procedures.
EMLA (2.5% lidocaine and 2.5% priolocaine can be administered 60 minutes prior to the procedure and can penetrate about 10 mm into the skin. Occlusion can get into the skin further and possibly faster, Dr Lio said. There is a risk for methemoglobinemia for patients younger than 3 months or when larger amounts of the product are used, such as during laser hair removal on the back. Two options that work within 30 minutes are tetracaine and liposomal lidocaine, which is a newer product.
Dr Lio shared a pearl for reducing immediate and delayed pain from cryosurgery. He recommended applying compounded 4% lidocaine cream immediately after freezing a wart, for example, which improves absorption and numbness in 30 seconds and makes the procedure more comfortable for the patient.
While injectable local anesthetics are safe, work rapidly, and are cost-effective, the initial injection is associated with discomfort. To reduce pain from the needle, Dr Lio recommended using a topical anesthetic. For pain associated with infiltration of the medication, he suggested warming the lidocaine to room or body temperature, injecting first into the deep dermal layer and slowly injecting to the surface to reach the superficial layer while reducing pain sensation.
Another option, which has to be compounded, is to use sodium bicarbonate as a buffer (every 1 ml of bicarb use about 9 ml of lidocaine), Dr Lio said. While issues related to potency and shelf-life, among others, have not been found for compounding lidocaine and bicarbonate in studies, some hospitals outlaw this, he added.
For patients really concerned about lidocaine, the saline kiss, which is bacteriostatic saline (with benzyl alcohol), reduces pain and is less uncomfortable, said Dr Lio.
Cooling the skin is another important part of pain management because it decreases nerve conduction and pain transmission. Commercially available sprays of ethyl chloride, ice pack, preferably made from aluminum foil as opposed to a glove, can be used to cool the skin. Vibration, as Dr McQueen discussed early, also decreases pain application and can be used with cooling agents to get the best of both worlds, Dr Lio said. These techniques are cost-effective, easy to use, reusable, and can even improve blood draws in children, he added.