Acute pain management in dermatology Risk assessment and treatment

1. Acute pain management in dermatologyRisk assessment and treatment J Am Acad Dermatol 2015

2. INTRODUCTION • Dermatologists perform many procedures that require acute pain control with local anesthesia and, in some cases, management of postoperative pain • When Acute postsurgical pain (APSP) is disregarded or provider interventions are inappropriately applied, patients are at greater risk for poor satisfaction and complications, including inferior wound healing, bleeding, insomnia, cardiovascular sequelae, transition to chronic pain, substance abuse, future exaggerated hyperalgesia, and psychological disorders

3. PREOPERATIVE PAIN MANAGEMENT • Identification of risks before surgery • Most dermatology procedures are of short duration and minimally invasive Therefore, they confer low risk • Others are more extensive, such as excisions, skin grafting, resurfacing, and intuitively suggest a higher risk for APSP • multiple same-day procedures and younger age are associated with greater APSP • surgery site, size of defect, amount of wound tension, and type of closure are not as clearly associated with APSP

4. Demographically, females and younger patients (especially those<31 years of age) are at greater risk for APSP • Obesity, a history of or a tendency towards pain catastrophizing, a history of depression, regular opioid or anxiolytic use, or a history of an underlying hyperalgesiasyndrome predict postsurgical hyperalgesiaseverity

6. Pain assessment scale for monitoring There are 4 commonly used, validated scales for APSP • The Wong Baker Faces pain scale is a recognized and validated tool for assessing APSP in children >3 years of age and adults • numerical rating scale [NRS]) is validated for adults and is arguably the easiest to integrate. This scale assigns a numeric value for pain severity from 1 to 10, with 10 being most severe • visual analogue scale (VAS) requires patients to place a mark between 2 endpoints on a line, which represents the spectrum of pain from no pain to severe pain and is assigned a value from 0 to 100

7. 4. A categorical rating scale (CRS) uses categories of pain (ie, none, mild, moderate, and severe) • It is critical to assess pain both before and after the intervention to identify efficacy • While it is important to assess APSP severity at rest, evaluating APSP on activity is more critical. Controlling this dynamic pain will have a greater impact on promoting postprocedure mobilization and, therefore, prevent many complications

9. Patient education • Preoperative education about pain physiology and patient-directed pain management strategies may be helpful modulating cortical responses to and mitigating pain for high-risk patients • for example, Fincher et alreported significant improvement in pain scores among children who were given preoperative education about a procedure and equipment used • there is greater retention of preoperative information when delivered by multimedia content forms, such as videos or audioaugmentedslides, over written methods, which are themselves superior to verbal instructions

10. OPERATIVE PAIN MANAGEMENT • Locoregionalanesthesia • it has obvious safety advantages over general sedation, including greatly reduced morbidity and mortality risks, decreased respiratory monitoring and nursing support requirements, rapid onset, and retaining cooperation of the patient • Locoregionalanesthetic agents are divided into 2 classes (aminoestersand aminoamides) based on the covalent bonds that connect the hydrophobic and hydrophilic components of the molecules

12. procedures with an obvious low risk for APSP, such as obtaining a shave biopsy specimen, may be better served with an anesthetic with a short half-life, such as lidocaine • In contrast, a 5-cm excision in a patient with a history of pain catastrophizing may be better served with an anesthetic with a long halflife, such as bupivacaine • a patient’s comorbidities and concomitant medicationswill also direct anesthetic choice • For example, bupivacaine and etidacaine should be used cautiously in patients with high-risk cardiac disease or taking medications, such as betaadrenergicblockers, digitalis preparations, calcium channel blockers, and phenylephrine

13. The use of less cardiotoxic anesthetics, such as lidocaine or mepivacaine, with a short onset time and intermediate duration, or regional nerve blocks should be considered in these • Metabolism of both esters and amides occurs, at least in part, in the liver via the P450 monoxygenase or Cytochrome p450 enzyme system • In addition, metabolism of both esters and amides are affected by liver disease, pseudocholinesterasedeficiency, and some prescription or herbal medications, such as midazolam, ginseng, and gingko • Therefore, dosing of local field therapy should be reduced by <50% to minimize the risk of toxicity or consider an alternative method, such as a nerve block, to reduce the amount used or tumescent anesthesia to dilute the anesthetic

14. Systemic toxicity starts with paresthesia of the tongue and lips and progresses to metallic taste, tinnitus, agitation, fasciculation, seizures, respiratoryarrestand, if plasma concentrations are high enough, cardiac arrhythmias, such as prolonged PR interval, widening QRS and supraventricular tachycardia, and severe cardiovascular collapse • Toxicity may be seen as early as 5 minutes, but can be seen as long as 30 minutes after infiltration

15. Multiple administration techniques are available, including percutaneous, infiltrative, and regional anesthesia • Percutaneous anesthesia is the topical application of an anesthetic agent by way of iontophoresisor application of spray for mucous membranes or creams/ointments for cutaneous sites. It is most appropriate for use in anticipated superficial procedures involving small areas to mitigate the pain of infiltrative anesthesia

16. Infiltrative anesthesia most commonly used for obtaining biopsy specimens, excisions, curettage and electrodessication, and small flaps and grafts • It can be administered directly under a lesion, but for large areas or when a surgical site needs to be minimally disturbed, such as removing a cyst, a ring block can be administered with a ‘‘fan’’ technique around a site • Tumescent anesthesia is a variant of infiltrative anesthesia that uses large volumes of diluted anesthetic agent for use in large surgical fields and for patients with comorbidities, such as liver disease or cardiomyopathy

17. Multiple formulas are used, most commonly with lidocaine 0.05% to 0.1% with epinephrine diluted in 0.9% normal saline or Lactated Ringers • although popularly associated with liposuction, tumescent anesthesia has potential use for large flaps and other procedures, such as intralesionalbleomycin, sclerotherapy, and large excisions • Regional anesthesia is the injection of small volumes around selective nerves for the regional elimination of pain. Consequently, large surface areas can be anesthetized using smaller total anesthetic volumes • Nerve blocks are appropriate for nasal tip, the upper lip, and digits,, or for broader coverage of the entire hand or foot

18. Local anesthesia pain reduction • local anesthesia, however, causes acute pain in and of itself because of the needle and the anesthetic properties, such as its pH and pKa • The best evidence for a single intervention is for the use of so-called ‘‘buffered lidocaine,’’ a preparation consisting of sodium bicarbonate 8.4% and lidocaine1% or 2% with epinephrine in a 1:10 ratio • Buffered Lidocaine must be used within 1 week • other interventions may decrease pain associated with injection include warming the lidocaineto body temperature (eg, rolling the filled syringe in the palms), counterirritationthrough pinchingor vibration, or skin cooling. The use of vibratory stimulation devices

19. Several techniques have been reported, including applying a device at or near the injection site before injecting or applying the device in a circular motion to nearby tissue and simultaneous injection • Preinjection cooling using ice or cold saline bags (48C) for 1 to 5 minutes has also been shown to be an individually effective method of reducing injection • needle size in the gauges used for most dermatologic procedures (ie, 27-31 G) likely tend to decrease the injection pain associated with intradermalinjections • pause after an initial subdermal injection with a small aliquot before injecting slowly (eg, over 30 seconds) larger volumes and reinserting the needle within 1 cm of blanched areas

21. psychological interventions can be used to reduce APSP in certain patient populations. For example, hypnosis or distraction techniques, such as watching videos, listening to music or talking, reduce pain experiences, especially for children and adolescents. Newborns benefit from swaddling or sucking-related interventions, but there is no consistent data showing an effective psychological intervention for older infants

22. Perioperative anxiolytic • Benzodiazepines are excellent amnesticsand anxiolytics that may be administered intranasally, orally, or intravenously • orally administered midazolam 10 mg significantly reduced patient perioperative anxiety and blood pressure • However, adverse effects include, most notably, drowsiness and respiratory depression, which require commitment of nursing resources to intra and postoperative patient monitoring for<1 hour after the procedure, and may impact postsurgical mobility and independence • Their use may be limited by adverse side effects and the extra staff they required for patient monitoring

24. Preventive analgesia • Preventive analgesia techniques, such as singledosemedication administered before, during, or immediately after a procedure have some efficacy in reducing intra- and postoperative pain <24 hours after a procedure, reduce opioid use, and prevent hyperalgesia syndromes • Comparing single-dose ibuprofen 400 mg to low-dose celecoxib 200 mg or celecoxib400 mg after minor surgery, there is no difference in pain relief in the first hours, but pain relief lasts longer (24 vs. 9 hours) in patients who were treated with celcoxib

25. the use of preemptive analgesia may be most effective when a multidoseapproach is used • For example, celecoxib200 mg given every 12 hours starting the night before a face lift significantly reduced pain scores compared to a single dose of a nonsteroidalanti-inflammatory drug (NSAID) before surgery • Although the use of other intraoperative adjuvants, such as gabapentinoids, benzodiazepines, glucocorticoids, for perioperative analgesia and antihyperalgesiahave not been evaluated specifically in dermatology, other surgical specialties have found preventive adjuvants useful in mitigating severe APSP

26. Gabapentin,whenadministered 1 to 2 hours before surgery in doses of 300 to 1200 mg, has significant analgesic effect compared to placebo • In addition, gabapentinoidsmay also reduce the risk of chronic postsurgical pain • Glucocorticoids, such as intravenous dexamethasone show significant but limited analgesic effects with no concomitant increased risk for wound infection ornausea when administered perioperatively in general surgery, but its route and potential for complications, such as hyperglycemia, are likely prohibitive in dermatology • randomized controlled trials of benzodiazepines in minor procedures have not shown clinically significant analgesic effects

27. POSTOPERATIVE PAIN MANAGEMENT • Cold analgesia • While pain and temperature are carried by C fibers, stimulating temperature receptors may override pain signals and edema and may significantly reduce APSP scores after mucocutaneousprocedures • Acetaminophen • Acetaminophen remains the mainstay of pain management for minor dermatology procedures • significantly, this is not dose-dependent, and therefore lower doses are recommended

28. Acetaminophen administered at 1 g by mouth every 6 to 8 hours has rare, significant side effects, such asStevenseJohnson syndrome and liver failure, in the usual dose range of >4 g per day (3 g per day in patients [60 years of age), but at higher doses does have a risk of hepatic toxicity • Acetaminophen is the preferred analgesic in patients with advanced liver disease, because of the risks of bleeding and hepatorenalsyndrome. For these patients, their maximum daily dose is reduced to 2 g per day

29. Nonsteroidalantiinflammatory drugs • NSAIDs recommended first-line therapies for the treatment of mild to moderate APSP • patients [65 years of age or with a history of peptic ulcer disease concomitantly be given gastroprotectiveagents, such as misoprostol 200 g4 times daily or omeprazole 20 mg daily • Acute side effects are rare, but include StevenseJohnsonsyndrome, nausea, vomiting, and tinnitus in healthy patients • Aspirin, a salicylate, is a nonselective NSAID that is predominantly used for its cardioprotectiveeffects at low doses and is not commonly used for pain control because of its side effects and access to safer alternatives, such as ibuprofen

30. aspirin has been shown to be generally effective for <12 hours for the treatment of moderate to severe APSP at high single doses of 900 to 1200 mg immediately postoperatively • The clinical implications, however, for wound complications—such as hematomas, dehiscence, or bleeding—that are directly related to postoperative NSAID use are conflicting • for minor dermatologic procedures, such as obtaining a biopsy specimen and small excisions, the use of NSAIDs in general likely confers a low risk for bleeding complications

31. Indirect evidence in marketing studies suggests that the postoperative use of ibuprofen does not confer greater bleeding complications to wounds compared to acetaminophen • the use of ketorolac may be linked to bleeding complications and there may be different risks for adult and pediatric populations

33. Nonsteroidalantiinflammatory drugscompared to acetaminophen • metaanalyses show that for minor procedures, NSAIDs at a dosing of ibuprofen 200 to 400 mg are superior to acetaminophen 600 to 1000 mg for acute pain control when given in the first 6 hours postprocedure • combination of ibuprofen and acetaminophen maybe safe and superiorto either rmedication used alone immediately after minor procedures to manage moderate to severe acute pain in adults and children

34. Opioids • Opioids target opioid receptors in the spinal cord and cortex • There are 4 classes of opioids, consisting of phenanthrenes, benzomorphans, phenylpiperidines, and diphenylheptanes, as well as atypical opioids • Class distinction is important when choosing an opioid for a patient with the rare true allergy, because an opioid from a different class can be selected in these situations

36. Opioid recommended for moderate to severe pain management, but in reality they are often used for mild to moderate pain, too • the analgesic effect can be rapid and effective in many cases, and dosing ranges are broad, limited only by side effects • Codeine • 10% of patients lack the enzyme to metabolize codeine and therefore get no analgesia (pain relief comes from the acetaminophen component only); • 1% to 2% of patients are ultrarapid metabolizers, and may suffer severe opiate intoxication

37. opioid • In 1 review of acute postoperative pain, oxycodone 5 mg was inferior in providing <50% pain relief over 6 hours after surgery to ibuprofen 400 mg or ibuprofen 400 mg/oxycodone 5 mg • the class’ adverse effect profile makes it a second-line therapy for postoperative pain control after minor procedures • More seriously, opioid use is associated with the paradoxical development of hyperalgesia, which can impact future pain medication dosing requirements and pain perception

38. regular opioid use for as little as 1 week can lead to dependence and the acute complications of withdrawal • For patients for whom tolerance has developed, such as patients concurrently taking an opioid, taking the opioid before and after the procedure and augmenting with additional analgesia is appropriate

39. Combination medications • Monotherapy is sometimes not adequate for pain relief • Combining acetaminophen and an NSAID, for example, shows significant analgesic effects for moderate to severe pain with minor and expected side effects related to each drug • In addition, the combination of acetaminophen and ibuprofen showed superiority to acetaminophen 325 mg/codeine 30 mg after MMS • More research should be conducted examining the efficacy and risk of harm when combining new or nontraditional combinations, such as gabapentin and ibuprofen

41. Adjuvant medications • Adjunctive medications target cortical structures and are typically used to treat common psychological pathology and cancer pain • This approach should be considered in the management of chronic rather than acute pain • recent studies suggest that adjuvants, like fluoxetine, may have antiinflammatoryand antihyperalgesiceffects