The sweet smell of relief — easing pain during procedures

Taking the sting and anxiety out of dermatology procedures is half the battle for putting patients at ease and achieving a successful outcome. The pain doesn’t really disappear, but a number of tips can help manage it in both children and adults, according to Peter A. Lio, MD, a professor of dermatology at Northwestern University’s Feinberg School of Medicine in Chicago, and Alisa McQueen, MD, an associate professor of pediatrics at the University of Chicago’s Comer Children’s Hospital. The two led the session “Pain-free Dermatology: Minimizing Discomfort in Procedures for Children and Adults” (U024).

Peter A. Lio, MD.

Procedures are an integral part of dermatology, but unfortunately, many entail some degree of pain or discomfort. In the past decade, there have been a number of studies that target the goal of managing pain and anxiety in office and emergency department settings. These same concepts can be directly applied to dermatology procedures, Dr. Lio said.

“There are many procedures that bring pain and anxiety, including skin biopsy, laceration repair, freezing a wart or an actinic keratosis, excision, neurotoxin injection, setting a fractured bone, relocating a dislocated joint, and even suture removal,” Dr. Lio said. “We feel strongly that with certain techniques and approaches, both pain and anxiety can be lessened and, in some cases, almost completely mitigated.”

Words make a difference

Alisa McQueen, MD.

In many cases, it’s as simple as reframing the terminology, Dr. McQueen said. For example, she suggested avoiding certain terms, such as “painful,” “needle,” and “going to hurt.” Instead, Dr. McQueen offered alternative language, such as telling the patient the medicine will feel “tingly” or “warm” instead of “burn.” Additionally, dermatologists can reverse negative thoughts by flipping the narrative, Dr. McQueen said. For example, dermatologists can avoid telling the patient what it will feel like and instead ask the patient to tell you what it feels like. Better yet, distract the patient with unrelated conversation about their day or themselves.

Finally, don’t forget the power of technology, Dr. McQueen said. Leverage distraction tools, such as interactive games on a tablet or iPad.

Combining these distraction techniques with treatments such as topical anesthetics, cooling, and vibration devices work synergistically to minimize discomfort. Topical anesthetics can last from minutes to hours and are generally safe with limited side effects, Dr. Lio said. A commonly used preparation is an “Eutectic Mixture of Local Anesthetics,” which is composed of 2.5% lidocaine and 2.5% prilocaine. One study noted that cooling methods for pain mitigation were just as effective as pharmacologic solutions. Cooling methods can involve anything from evaporative refrigerant sprays to ice cubes wrapped in latex material or aluminum foil, he said.

Sweet solutions and aromatherapy

Don’t underestimate the power of sucrose in young children. Dr. McQueen discussed using a sucrose solution to decrease perceived pain around procedures such as heel stick blood draw in neonates. Dr. Lio discussed aromatherapy and noted one study that examined 73 children with type 1 diabetes who had to perform regular insulin injections. During the injections, the room was suffused with orange and lavender oil, resulting in lower heart rates among those in the study.

Pros and cons

Lecturers  presented mounting evidence that supports different techniques for pain mitigation and discussed the pros and cons of certain techniques for specific dermatology procedures.

“Beyond being a positive outcome in and of itself, the main pro is that when the patients are more comfortable and less stressed, it turns out that procedures are more likely to actually be successful,” Dr. Lio said. “The main cons are that there is some added time, expense, and equipment involved in doing the procedures, and while not insurmountable for most, they do require some investment.”

Dr. Lio suggested costs are associated with things such as aromatherapy devices, consumer tablets, and other electronic devices.

Follow your training

As a reminder, Dr. Lio said dermatologists should be mindful of following appropriate techniques for procedures commonly performed in daily practice, including skin biopsy, excision, and cryotherapy. As for cryotherapy, he said, applying topical anesthetic immediately after a gentle cryotherapy treatment appears to stop the throbbing pain almost instantly.

“Minimizing discomfort is honestly fairly easy and has such an important outcome. Patients leave happier, less stressed, and with a higher chance of successful procedures,” Dr. Lio said. “It can make it that much more likely for patients to say, ‘That doctor was amazing!’”

Top