Distraction techniques are simple and effective ways to reduce anxiety and direct a patient’s attention away from a procedure. In addition to reducing pain and anxiety during procedures, these techniques can be applied to many areas of dermatology, such as addressing scratching behaviors.7 Dr Jaquez often gives patients with atopic dermatitis or other pruritic conditions a fidget spinner, fidget cube, or stress ball to help redirect the patient’s behavior and give them something to keep their hands busy.
Technology-based approaches work best during procedures, according to Dr Diaz. These can include games, music, and videos available on a tablet or on the patient’s cell phone. Noise-cancelling headphones can be offered for patients to drown out any noises from the procedure. “In younger children, an iPad with movies or games is more helpful, while noise-cancelling headphones with or without music tends to be more effective in older adolescents,” said Dr Diaz.
One effective strategy for reducing anxiety is giving patients a sense of control over certain parts of the procedure, within reason. For example, the physician can let the patient choose which distraction they would like to use during a procedure. If covering a patient’s eyes, letting them decide whether to hold something in their hands, or listen to music also gives them a sense of control. “From a psychological standpoint, the more perceived control we are able to give them, the better they are going to feel and the less anxiety they are going to experience,” said Dr Jaquez.
For patients who are very nervous or have needle phobia, Dr Diaz refers them to Dr Jaquez for separate sessions. Dr Jaquez will meet with the patient and their family to review various coping techniques to reduce their anxiety, as well as distraction techniques, prior to a procedure or treatment. “For patients with a normal level of fear of needles, which is the majority of mine and Dr Diaz’s patients, they may only need one or two sessions,” said Dr Jaquez. However, if they have significant needle phobia, the process is more involved.
“We use cognitive behavior therapy and also engage in exposure therapy with the family, with the final exposure working up to whatever treatment the patient needs,” said Dr Jaquez. She sets up the last session in the clinic in order to show patients how the skills they learned can be used during procedures or treatment, and also to provide extra support.
Prior to performing any injection or procedure, it is important to take the time to learn each patient’s needs and preferences. For example, “some patients prefer to know exactly what is happening and want to watch,” said Dr Jaquez. Others, especially those who have vasovagal reactions, will not want to watch or know what is going on during the procedure. Counting down to an injection, for example, can increase anxiety.
According to Dr Diaz, providers should not only listen to their patients but should also tell them what to expect, including the positive and the negative. She also noted that providers should remember they are advocates for their pediatric patients and should not let parents sway their decisions in a way that makes matters worse for the patient. “Our job is to help the patient and make it the most effective treatment in the least stressful way,” she said.
When to Not Proceed
“If a patient has needle phobia, do not move forward right away,” said Dr Diaz, adding that “this can actually cause secondary trauma and make their fear worse.” She recommended referring patients to a psychologist if possible. For patients who may not have access to a psychologist, she recommended taking baby steps, talking them through the procedure, and asking patients why they are scared and what can be done to make them more comfortable. Lastly, “do not let parents punish their children over their fears,” said Dr Jaquez. This is important, “especially for procedures that are going to be repetitive, because once the patient loses trust, or if the parent punishes them for being scared, then it will be a lot harder later on,” said Dr Diaz.
Reducing Pain From Injections
In his presentation at the American Academy of Dermatology Summer Meeting,8 Dr Lio reviewed steps for reducing pain from injecting local anesthesia, including:
- Use of a topical anesthetic prior to injecting;
- Compounding lidocaine with sodium bicarbonate;
- Warming lidocaine to room temperature;
- Cooling the skin with an ice pack prior to the injection;
- Using a vibrating device during the injection; and
- Injecting in the deep dermal layer first and slowly moving to the superficial layer.
Another option Dr Wu studied with his colleagues was the use of a small needle gauge. In a review of 318 cases, Wu et al9 found more than three-quarters of patients did not feel any part of the injection on their face. “If a patient is not even aware of a needle or any pain during the procedure, it would make sense that they would be less likely to avoid future surgeries if necessary,” said Dr Wu.
Managing vasovagal reactions and hypnosis on page 3