Procedural pain is something we encounter every day in dermatology, but it often doesn’t get the attention it deserves. Even quick procedures like biopsies, injections, or cryotherapy can cause significant discomfort, especially in kids, anxious patients, or those with needle phobia. While there’s a lot of research on managing surgical or chronic pain, there’s surprisingly little guidance focused specifically on minor dermatologic procedures.1,2 This review aims to fill that gap by highlighting simple, evidence-based strategies that dermatologists can use to make procedures more comfortable. We also emphasize integrative and non-pharmacologic tools like: virtual reality, aromatherapy, and vibration devices, that can make a big difference without adding extra steps or slowing down workflow. The goal is to give providers practical, patient-centered options to improve the experience of care while staying efficient in a busy clinical setting.
A review of the literature from the past decade was conducted using PubMed. Search terms included: “pain management and dermatology,” “pain management and dermatology procedures,” “acute pain management in dermatology procedures,” and “pain management and topical spray.” Studies published from May 2015 to the present were included if they focused on evidence-based strategies for managing procedural pain in dermatology. Articles were excluded if they lacked clinical relevance or did not directly address procedural pain. In addition to database searches, reference lists of key articles were manually reviewed to identify further relevant studies.
The selected data were organized into two main categories: pharmacologic strategies (eg, topical and injectable anesthetics) and non-pharmacologic approaches (eg, distraction techniques, vibration therapy, aromatherapy, and cooling methods).
Pain perception during dermatologic procedures can vary widely based on several factors. Physiologically, nerve fibers respond to noxious stimuli, while psychologically, things like anxiety, past experiences with pain, and individual coping styles all play a role in how a person reacts to discomfort or pain.1,2 Pediatric patients often perceive and react more strongly to discomfort or painful stimuli, leading to heightened stress and anxiety during procedures. Because of this, there has been a strong emphasis on managing pain early on, using techniques like distraction, parental touch, and even involving child life specialists to help support children throughout their care.2,3 Children are particularly vulnerable to the long-term consequences of unmanaged pain. Studies show that a large percentage of children, up to 63%, report fear of needles, and these early negative experiences can develop into lasting phobias in adulthood. The data also highlight that children between the ages of 5 and 10 years are at the greatest risk of developing needle-related fear, reinforcing the importance of early, developmentally tailored interventions during procedures to help prevent fear conditioning and future avoidance behaviors.4 In contrast, adult patients often don’t receive the same level of support during painful or uncomfortable procedures, and there’s still a noticeable gap in research focused on effective pain control for adults in dermatologic settings.3,5
Addressing pain and fear during dermatologic procedures is crucial, as these factors can create strong barriers to care, lead to traumatic experiences, and lower patient satisfaction. When not properly managed, they can affect whether patients follow through with treatment or seek care in the future, highlighting the need for effective pain management strategies in both pediatric and adult populations.1–3
Virtual Reality (VR) is an emerging digital distraction technique that has shown promise in managing acute procedural pain in children. A 2020 review analyzed 17 randomized control trials involving over 1,000 children aged 4-18 and found VR to significantly reduce self-reported pain and distress during needle-related and other acute procedures. It is thought that the immersive nature of VR allows children to be fully engaged, and their attention remains focused away from the painful stimulus.6
Distraction tools such as VR, noise-canceling headphones, and electronic devices have all been shown to help reduce both pain and anxiety in pediatric patients.7 Both VR and noise-canceling headphones led to notable decreases in pre- and post-procedural anxiety.3,7 While one study did not find a clear advantage of one method over the other, it did suggest that noise-canceling headphones may be more accessible in clinical settings and more cost-effective overall.7
In addition to dermatologic literature, VR has shown consistent effectiveness across a broad range of acute and chronic pain conditions. A 2023 umbrella review by Viderman et al concludes that VR effectively reduces both acute and chronic pain, offering meaningful relief with a favorable safety profile and broad applicability across various fields.8 A more recent 2024 review supports these findings highlighting VR’s consistent effectiveness and high patient satisfaction across perioperative, procedural, and chronic pain settings.9 Furthermore, Ahmadpour et al also reports significant reductions in pain and anxiety across clinical trials, emphasizing the importance of tailoring VR content and integrating it into routine care.10 Together, these comprehensive reviews support the use of VR in dermatology by drawing on established pain management protocols and allow clinicians to implement patient-centered digital distraction strategies that are both evidenced-based and practical for daily use.
Some methods of sensory modulation include vibratory devices and cooling techniques. Studies have shown that vibration can significantly reduce pain during injections, especially when combined with cooling. This approach has been effective in both pediatric and adult populations, making it a simple and practical tool for minimizing discomfort during procedures.11–13 One vibrating device (Buzzy®), which combines cold and vibration stimuli, has been studied for its effectiveness in reducing pain during procedures. One study found that the device significantly decreased both pain and anxiety levels in children undergoing needle-related procedures. This supports its use as a simple, non-invasive option to help improve comfort during minor interventions.14
Cooling measures applied to the skin before a procedure have been shown to reduce pain perception by slowing nerve conduction. Vapocoolant sprays, in particular, are valued for their rapid onset and ease of use during procedures. Studies have demonstrated that both pre-injection cooling and the use of coolant sprays can help lower pain levels and reduce the need for additional anesthetics.15–17 Incorporating such measures can improve patient comfort and increase compliance during dermatologic procedures.
Parental touch and music therapy have both been shown to independently reduce pain and anxiety during procedures, particularly in pediatric patients.3,18 Aromatherapy, especially through the inhalation of essential oils like lavender, has also been effective in lowering pain and anxiety during and after procedures, as demonstrated in randomized controlled trials in postoperative settings. This approach has shown a strong safety profile and holds real potential for integration into dermatology clinics. While there is no definitive evidence that combining music therapy with aromatherapy is more effective than using either alone, the combination remains highly feasible and practical for clinical use in dermatologic care.18–20
Expanding on this, recent systematic reviews and clinical trials confirm that aromatherapy is an effective adjunct for managing both pain and anxiety. A 2016 meta-analysis conducted by Lakhan et al showed significant reductions in acute and chronic pain when aromatherapy, particularly lavender oil, was incorporated into pain management protocols.21 Additionally, a separate systematic review examining postoperative recovery settings found that administering aromatherapy in the recovery room led to meaningful reductions in patient-reported pain, emphasizing its benefits not only during but also after procedures.22 In another randomized control trial, Singh et al demonstrated that patients receiving aromatherapy prior to interventional pain procedures experienced significantly reduced procedural anxiety compared to those receiving standard care.23 Although studies in dermatology are still emerging, the strong evidence from pain medicine and perioperative care supports aromatherapy as a safe, low-cost, and easily implementable strategy to improve patient comfort and satisfaction in dermatologic settings.
Building on this, clinical hypnosis has gained recognition as an effective psychological intervention for managing procedural pain and distress in children. A 2023 scoping review analyzed 38 studies involving over 2,200 pediatric patients and found that clinical hypnosis outperformed standard care and other nonpharmacologic methods such as distraction or acupressure. Of the studies reviewed, 76% reported moderate to large reductions in pain and distress. This technique works by guiding the child into a focused, relaxed state, making them more receptive to therapeutic suggestions that help shift their perception of pain.
Recent comprehensive meta-analyses further support the effectiveness of hypnosis for pain relief across a variety of clinical and procedural settings. Milling et al conducted a large meta-analysis showing that hypnosis produces moderate to large reductions in both acute and chronic pain while also demonstrating its effectiveness both as a standalone intervention and when combined with standard care.24 Additionally, Thompson et al reviewed 85 controlled trials and found consistent, significant pain reduction with hypnosis compared to control groups, emphasizing its reliability across patient populations.25 Another study by Kendrick et al focused on acute procedural pain and concluded that hypnosis reduces pain, lowers stress, and lowers procedural anxiety, especially when protocols are personalized to patients.26 While studies specific to dermatology are limited, these findings offer well-established protocols that can be adapted to dermatologic procedures as a way to manage pain.
Topical anesthetics commonly used in dermatologic procedures include lidocaine, prilocaine (often combined with lidocaine in formulations like EMLA), tetracaine, and newer options such as liposomal lidocaine. Lidocaine is typically preferred for short procedures due to its quick onset and reliability. Combination creams have been shown to provide deeper anesthesia and faster onset, especially when used with occlusion methods like plastic wrap to enhance skin absorption.2,15,27 Liposomal formulations and occlusion methods have been shown to improve absorption and reduce the time to onset for topical anesthetics. When combined with additional techniques like vibration or cooling, these approaches can further enhance pain relief. However, topical anesthetics are generally less effective beyond the stratum corneum and often require a significant amount of time to take effect. For example, EMLA requires around 60 minutes, tetracaine about 30 minutes, and liposomal lidocaine typically 15–20 minutes. In a busy clinical setting, these time demands may not always be practical.2,15,27
There are several ways to optimize the use of injectable local anesthetics during dermatologic procedures. Using smaller gauge needles can help reduce pain perception during injection.1 Warming the lidocaine solution beforehand has also been shown to enhance patient comfort.1 Another common method is buffering lidocaine with sodium bicarbonate, which reduces its acidity and lessens the burning sensation upon injection. Buffered lidocaine is commonly used as a local anesthetic in minor dermatologic procedures to help reduce injection pain.28 It is conventionally mixed with sodium bicarbonate to lessen the burning sensation patients often feel. However, one study looked at an alternative approach by comparing saline- “buffered” lidocaine to the standard bicarbonate-buffered version in patients undergoing central line placements.28 The study found no significant difference in pain scores between the two groups, suggesting that saline, a more readily available option, can be just as effective.28 While this study did not specify if they used bacteriostatic saline or not, other studies have underscored the importance of using bacteriostatic formulations as they contain benzyl alcohol.28 Benzyl alcohol itself can serve as a local anesthetic and may actually prolong the efficacy of co-administered injectable anesthetic agents.28 This gives clinicians more flexibility in managing injection discomfort, especially when sodium bicarbonate isn’t available or can’t be used.28
Patients also often report less discomfort when lidocaine is injected slowly, allowing for a more tolerable experience. For longer procedures such as complex excisions or Mohs surgery, longer-acting anesthetics like bupivacaine are preferred, as they have been shown to significantly reduce postoperative pain (See Table 1).1–3,5,29
Distraction via immersive visuals/audio
Significant anxiety reduction
Less accessible in smaller clinics
6,7,9-11
Auditory distraction
Effective, more accessible than VR
Not superior to VR, limited studies
7
Auditory relaxation
Effective alone or with aromatherapy
Dependent on patient preferences
3,18
Opioid receptor-mediated calming
Significant pain & anxiety reduction
Requires scent tolerance and preparation
18-23
Comfort through physical presence
Reduces child distress
Not applicable to adults
3
Neural gate theory disruption
Statistically significant pain reduction
Not effective in every case, device cost
8,12-14
Nerve conduction delay
Moderate to high effectiveness, fast acting
Less effective than EMLA for deep pain
15-17
Focus shift (eg, tablet games)
Some pain reduction
Small sample sizes, variable success
3
Sodium channel blockade
Effective but delayed onset
Messy, time-consuming
1,2,28
Enhances anesthetic penetration
Improves absorption, reduces wait time
Requires additional setup
1,2
Prolonged action, improved delivery
Rapid onset, deeper penetration
Limited pediatric data
28
Reduced acidity and discomfort
Improves comfort significantly
Needs precise technique
1,29
Long-acting local anesthetic
Reduces postop pain, narcotic use
May be underutilized, cost concerns
1-4,30
Endogenous opioid activation
Effective in infants <1 year
Limited to very young patients
2,17
High-pressure delivery without needles
Useful for needle-phobia
Costly, inconsistent efficacy
31
Newer needle-free jet injection systems may offer a solution for patients with needle phobia. A randomized clinical trial by Lunoe et al looked at the effectiveness of a device which delivers lidocaine intradermally without a needle, in children aged 1 to 6 undergoing venipuncture. The study found that children who received lidocaine through the device had significantly lower pain scores compared to those who received a vapocoolant spray or a sham treatment. These findings support the use of needle-free anesthetic options like jet injection as an effective way to reduce procedural pain in younger pediatric patients.30 However, other studies have shown inconsistent results, and the relatively high cost makes them less practical for routine use (See Table 2).
Current pain management strategies in dermatology include both pharmacologic methods such as topical and local anesthetics, and non-pharmacologic techniques like distraction, vibration, and cooling. These approaches are well-established, well-documented, and shown to be effective with strong evidence supporting the use of virtual reality, music, and parental touch to reduce pain and anxiety. Recent advancements, such as liposome-encapsulated lidocaine, have further improved comfort, especially when combined with methods like vibration or cooling. Despite these developments, many of these strategies have yet to be fully implemented in adult dermatology, where painful procedures still occur regularly. This reveals a clear gap and a lack of standardized, protocol-driven approaches to pain management in adult patients.2,3,11
Despite these advancements, it is important to recognize that procedural pain in dermatology shares both similarities and differences with chronic pain conditions. Procedural pain is typically short-term, occurring during or immediately after interventions such as biopsies, injections, or laser treatments.1,31 In contrast, chronic pain persists for three months or longer and may arise independently of a clear procedural trigger, often involving changes in the way the nervous system processes painful stimuli.21,31 Both acute procedural pain and chronic pain can be exacerbated by patient factors such as fear, anxiety, or prior negative experiences.2,4 For instance, individuals with needle phobia may experience heightened discomfort during procedures, much like chronic pain patients whose symptoms may intensify with psychological stressors.3,31
While traditionally managed separately, there is growing evidence that several psychological and non-pharmacologic strategies commonly used in chronic pain management such as relaxation techniques, hypnosis, and aromatherapy, can modulate central pain processing and demonstrate efficacy when adapted and applied in acute, procedural pain settings.2,21,32 This overlap in effective interventions points to shared neurobiological pathways in how we perceive pain and supports using chronic pain techniques to improve procedural pain control. Non-pharmacologic approaches including virtual reality, aromatherapy, and hypnosis directly target how the brain perceives pain and have shown benefits across both acute and chronic settings.7,21,32 Still, treatment approaches naturally differ with procedural pain responding best to fast-acting options like topical anesthetics, vibration, or cooling sprays,1,14 while chronic pain typically requires longer-term solutions like medication, physical therapy, and psychological support.31 By recognizing both the similarities and the differences, dermatologists can work towards building better pain management plans to relieve discomfort in the moment and potentially prevent longer-term pain after procedures.
Looking ahead, the development of rapid-acting, deeply penetrating topical anesthetics could help overcome the current limitations of traditional formulations. Existing agents are often restricted by their slow onset and shallow depth of penetration, which limits their effectiveness, especially in busy outpatient settings where time is a critical factor. This highlights the need for newer formulations that offer faster, more predictable, and deeper anesthesia to better reduce discomfort, pain, and anxiety during dermatologic procedures.2,27 Technology-assisted pain management has introduced innovative approaches such as virtual reality and noise-canceling headphones to improve patient comfort. In the future, emerging tools like AI-driven monitoring of patient anxiety and real-time feedback systems could further enhance the patient experience, especially for those with heightened procedural anxiety.7
While both pharmacologic and non-pharmacologic approaches have independently demonstrated effectiveness, exploring their synergistic benefits such as: combining buffered or warmed lidocaine with vibration, aromatherapy, or cooling, may offer even greater relief. Future studies examining these combinations are essential for establishing evidence-based, patient-tailored practices that optimize both pain and anxiety outcomes during dermatologic procedures.1,11
Moving forward, clinical guidelines should emphasize a personalized approach to pain management, tailoring strategies to each patient when appropriate. This includes systematically assessing individual pain and anxiety factors and incorporating complementary modalities into routine practice. Developing clear, practical recommendations and protocols can enhance the effectiveness of clinical care across both pediatric and adult populations.1
Minimizing procedural discomfort is essential for improving patient experience, satisfaction, and adherence to both current and future dermatologic treatments. While pediatric dermatology has benefited from a wide range of well-studied and systematically implemented pain management strategies, adult dermatology remains less explored and often lacks consistency in application. The evidence supports that combining pharmacologic and non-pharmacologic approaches, tailored to both the patient and the procedure, is the most effective way to alleviate pain and enhance comfort in dermatologic care.1,2,11
To move toward equitable, high-quality care, future research must address the critical gaps in adult pain management by developing novel agents, leveraging technology, and conducting comparative effectiveness trials. These efforts are essential for generating practical, evidence-based guidelines that can be integrated into routine care. By doing so, dermatology can ensure that patients of all ages benefit from safe, effective, and comfortable procedures whenever possible.1–3,11
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