Like most children, I hated shots. For me, this hatred manifested in the form of violent protests with lots of kicking and screaming. One time, I was forcibly restrained by my pediatrician because my screams were upsetting the other children in the waiting room, and on another occasion, I kicked a male nurse in the crotch. My parents were forced to take me to a new clinic each year for the annual influenza vaccine after I had caused a scene at previous clinics.
While my kicking days are (somewhat) behind me, the thought of any procedure requiring injections still invokes feelings of dread and nervousness related to both the injection itself and the visceral reaction my body now resorts to instead of kicking, medically referred to as a vasovagal reaction. The intensity of this bodily response for me can be as short as a few minutes or can leave me feeling sick for an entire day, depending on the level of pain and length of the procedure. Ever since my mother scared me straight with the threat of death from the flu because of my asthma, I continue to get my annual flu shot and age-appropriate vaccinations. However, all other medical procedures involving needles remains on the “not in a million years list.”
All jokes aside, a subgroup of the population faces similar fears and reactions to injections. A survey of parents and children conducted in Toronto, Canada, found that 24% of parents and 63% of children reported a fear of needles.1 In a systemic review of 119 studies by McLenon and Rogers,2 children were found to have the greatest fear of needles, and the prevalence of needle fear decreased by 8.7% for every decade increase in age. However, the authors2 also found the prevalence of needle fear ranged from 20% to 50% in adolescents and 20% to 30% in adults aged 20 to 40 years, though this also dropped with age. The estimated prevalence of blood-injury-injection phobia, which needle phobia is a part of, is between 3% and 4.5%.3
It is important to recognize and know how to discuss patient anxieties. Despite scant data in dermatology, other fields have shown that the needle-phobic patient population has a high prevalence of avoiding care, ranging from not having blood drawn to canceling dental procedures.2,3 This article addresses how to manage and reduce patients’ fears and anxiety of needles as well as treat vasovagal response.
Needle Phobia in Dermatology
Few studies have published data on the exact number of patients with needle phobia or vasovagal reactions in the field of dermatology alone. Furthermore, there are limited data on whether significant fear of needles or needle phobia is associated with patients refusing or delaying treatment in dermatology.
Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, IL (left).
According to Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, IL, it is rare for patients to refuse treatment due to needle phobia. “While it certainly does happen, I am able to get the vast majority of my patients, both children and adults, through the recommended procedure,” he said. He has had patients express fears and concerns about needles, but “it has been several months since I had someone categorically refuse a blood draw or treatment due to fear of needles.”
Wesley J. Wu, MD, Mohs micrographic surgeon for the Seattle Veterans Administration hospital and clinical instructor for the University of Washington department of dermatology in Seattle, WA (right).
Wesley J. Wu, MD, Mohs micrographic surgeon for the Seattle Veterans Administration hospital and clinical instructor for the University of Washington department of dermatology in Seattle, WA, noted that “perhaps [needle phobia and vasovagal] reactions are accepted as commonplace and going to the dermatologist may sometimes be viewed similarly as going to the dentist.” Despite possibly being a rare occurrence, with few studies on adherence related to needle phobia or vasovagal reactions, Dr Wu said, “it is conceivable that many patients delay seeking medical care and, subsequently, present with more progressive skin conditions, such as advanced skin cancers, because of a fear of the needle or the procedure itself.”
“Our goal is to help patients get better,” said Dr Lio, “and putting them through a major stressor probably works against us.”
Factors Associated With Phobias and Vasovagal Reactions
Based on the prevalence in other fields and the high rate of procedures that involve needles in dermatology,1-3 it is likely that a dermatologist will at least treat one patient with a significant fear or phobia of needles, as well as manage a vasovagal reaction.
Studies show female patients report needle fears more compared with male patients.2,3 In addition, other patient factors can contribute to a high risk for needle phobia, such as patients having a specific disease or condition. McLenon and Rogers2 showed the prevalence of needle fear ranged from 15.7% to 84% in patients undergoing chemotherapy, 1.3% to 41.7% in patients with diabetes, and 11.7% to 91% in patients undergoing routine dental procedures. Other conditions associated with a high prevalence of needle fear included allergies, asthma, multiple sclerosis, spinal conditions, and psychiatric disorders, as well as patients undergoing dialysis.3
The incidence of vasovagal reactions has been reported from 1% to 15% of blood donors and 10.6% among patients undergoing vein cannulation in ambulatory care centers, with women and younger patients most likely to experience vasovagal reactions.4 Other triggers include emotional distress, fear, pain, prolonged standing, warm environment, illness, alcohol intake, venipuncture and blood, fatigue, drugs, and menstruation, as well as insufficient food intake and dehydration.4
Addressing Fears in Children (and Adults)
There are many ways to reduce patient fear and anxiety prior to and during a procedure. For patients with a significant fear of needles or needle phobia, these techniques can help them cope with stressful procedures or even administration of necessary medications. The listed techniques can be used by most practicing dermatologists. However, if a patient presents with a phobia, they may need to be referred for outside support and exposure-based therapy.5
Lucia Diaz, MD, chief of pediatric dermatology at Dell Children's Medical Center of Central Texas (left).
Sasha D. Jaquez, PhD, pediatric psychologist and director of the Medical Coping Clinic at Texas Child Study Center (right).
Sasha D. Jaquez, PhD, pediatric psychologist and the director of the Medical Coping Clinic at Texas Child Study Center and Dell Children’s Medical Center of Central Texas, and Lucia Z. Diaz, MD, chief of pediatric dermatology at Dell Children’s Medical Center of Central Texas and an assistant professor of pediatrics and medicine in dermatology at Dell Medical School, published a review6 covering the techniques for reducing pain and anxiety during dermatologic procedures. “Even though we are discussing pediatric patients, the strategies can be applied to adult patients as well,” said Dr Jaquez. She suggested providers ask patients:
- How do you do with other procedures?
- Have you gone through this procedure before?
The patient’s answers to these questions will help determine the best approach, as well as identify patients who may experience vasovagal reactions, discussed later in this article.
Techniques on page 2