Implementing these strategies can greatly improve all experiences during dermatologic procedures. “The feedback we get from patients, and even the parents, is they feel more comfortable compared with a previous experience, and sometimes do not realize the procedure is over,” said Dr Diaz. “And, as the physician, or the resident doctors who work with me, we are more comfortable because the patient is not moving as much and are able to get done a little faster.”
Managing Vasovagal Reactions
“Spotting a vasovagal reaction early is vital, and it is important to act quickly,” said Dr Wu. During a vasovagal reaction, a patient’s blood is drained away from the brain into other areas of the body, such as the abdomen or muscles. The first visible symptoms include changes in lip pallor, irregular breathing, and clammy hands, which may be followed by sweating, shivering, vomiting, and possibly loss of consciousness. Patients may report dizziness and “graying” vision as well as nausea.4 The differential diagnosis of vasovagal reactions includes grand mal seizures, allergic reactions, cardiac syncope, hypovolemic shock, and cerebrovascular accident, among others.4
If a patient has a vasovagal reaction, “take their blood pressure and pulse immediately,” said Dr Wu. Tilting the patient’s head below the rest of the body (Trendelenburg position) can help increase blood flow to the head, he said. Placing a cold pack on the patient’s forehead, neck, armpits, or groin, raising the patient’s legs, and/or squeezing their hand are other effective techniques for treating vasovagal reactions. Once the patient returns to baseline facial color, heart rate, and blood pressure, they can be offered a drink with some sugar and/or caffeine.4 “I let the patient rest for at least 20 minutes before resuming any procedures,” said Dr Wu. “Thankfully, I have never had to employ any medical intervention, but a crash cart with atropine is always at hand,” he added.
To reduce risk of vasovagal reactions, patients should eat and drink before surgery and avoid alcohol, Dr Wu suggested. A nonthreatening environment is important for reducing anxiety, as well as the presence of a supportive family member or friend during the procedure.4
“During the visit, the main preventive technique is distraction, distraction, distraction,” said Dr Wu. This can be accomplished with any of the aforementioned techniques, such as letting patients listen to music or play games on their phone, if possible. “Talkesthesia,” which is talking to patients during a procedure, is also an effective distraction technique. Dr Wu also hides all instruments and blood from the patient’s view and instructs them to relax any areas of the body that may be tense, such as the shoulders. While these recommendations are for patients with vasovagal reactions, they can be used for all other patients to improve their experience while undergoing surgery. “In our clinic, we do our best to implement these for all of our patients,” he said.
In addition, Dr Wu sometimes offers preoperative benzodiazepines along with topical anesthetics for patients who tell him they experience fainting with certain procedures, as long as they do not have any contraindications and have a designated driver.
Hypnosis has been found to reduce anxiety and pain associated with dermatologic procedures.10 Dr Lio recommended this technique, which he said works about 80% of the time in his practice. He learned about hypnosis in medical school. In addition to needle phobia, “we also found good results for skin picking and scratching, as well as with anxiety and sleep issues that accompany skin diseases,” he said.
In his practice, Dr Lio refers patients who express anxiety about needles or procedures for hypnotherapy, and he has also worked with a hypnotherapist who specialized in needle phobia in children with diabetes for several years. For patients who are unable to afford a hypnotherapist, he recommends an inexpensive book that teaches self-hypnosis techniques.11 “One of the most wonderful aspects about this technique is patients can learn to hypnotize themselves,” he said.
During procedures, Dr Lio uses hypnosis techniques to help patients relax, such as having them close their eyes and imagine they are relaxing in their favorite spot. “It is like a mini-hypnotic induction, which I have patients do whenever I can,” he said. He also uses distraction techniques, which he said are akin to hypnosis. “I use it for excisions, especially those on the face. These can be very anxiety-provoking, as you can see and hear the procedure,” he added.
According to Dr Lio, it is important that more dermatologists learn about hypnosis. It is not commonly thought of in dermatology and even “carries with it an air of quackery,” he added. “I would vehemently argue that it is far from quackery and can give great benefit with very few risks to certain patients,” said Dr Lio. He hopes that more evidence is published showing the benefits of hypnotherapy in dermatology. “As we increasingly learn that mind and body are deeply connected in dermatology, it makes sense to leverage the effects of both whenever we can,” he said.
In my personal experience, a provider’s reaction when a patient discloses that they have a significant fear of needles and/or experience vasovagal reactions can make or break the patient-provider relationship, both in the moment and in the future. As an adolescent, many providers were dismissive of my fears and also did not believe me when I told them I fainted. As much as I hate almost passing out, I do feel somewhat vindicated when I see the look on a skeptical nurse’s face as my pallor changes drastically to bedsheet white. However, repeated exposure to these kinds of interactions with providers has really eroded my belief in a health care system that is intended to do no harm to patients, and I often delay seeking treatment because my trust in having a provider understand my fears and act accordingly was broken before young adulthood.
Most techniques for managing needle phobia and vasovagal reactions are not only simple to implement, but they are also supported by evidence or have strong anecdotal support from providers in various fields who administer injections or perform procedures regularly. Having a plan for addressing patients’ fears can not only improve the patient’s experience, but it can also improve the patient-provider relationship and help patients trust their providers.
If you are interested in further discussing this topic or have a technique you would like share with the audience of The Dermatologist, feel free to contact me at firstname.lastname@example.org. Dr Wu is also interested in discussing and learning about new techniques. He can be reached at email@example.com.
1. Taddio A, Ipp M, Thivakaran S, et al. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine. 2012;30(32):4807-4812. doi:10.1016/j.vaccine.2012.05.011
2. McLenon J, Rogers MAM. The fear of needles: a systematic review and meta‐analysis. J Adv Nurs. 2019;75(1):30-42. doi:10.1111/jan.13818
3. McMurtry CM, Pillai Riddell R, Taddio A, et al. Far from “just a poke”: common painful needle procedures and the development of needle fear. Clin J Pain. 2015;31(10 suppl):S3-S11. doi:10.1097/AJP.0000000000000272
4. Wu WJ, Goldberg LH, Rubensik MK, Zelickson BR. Review of the evaluation and treatment of vasovagal reactions in outpatient procedures. Dermatol Surg. 2018;44(12):1483-1488. doi:10.1097/DSS. 0000000000001598
5. McMurtry CM, Taddio A, Noel M, et al. Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research. Cogn Behav Ther. 2016;45(3):217-235. doi:10.1080/16506073.2016.1157204
6. Armenta AM, Jaquez SD, Levy ML, Diaz LZ. Use of psychologic strategies to reduce pain and anxiety related to dermatology procedures. Pediatr Dermatol. 2019;36(3):416-417. doi:10.1111/pde.13739
7. Schut C, Mollanazar NK, Kupfer J, Gieler U, Yosipovitch G. Psychological interventions in the treatment of chronic itch. Acta Derm Venereol. 2016;96(2):157-161. doi:10.2340/00015555-2177
8. Lio PA, McQueen A. Pain-free dermatology: Minimizing discomfort in procedures for children and adults. Presented at: 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.
9. Zelickson BR, Goldberg LH, Rubenzik MK, Wu WJ, Sinai M. Parallel, minimal needle-insertion technique for achieving a painless injection of local anesthetic. J Am Acad Dermatol. 2017;77(2):369-370. doi:10.1016/j.jaad.2017.03.007
10. Shenefelt PD. Biofeedback, cognitive‐behavioral methods, and hypnosis in dermatology: is it all in your mind? Dermatol Ther. 2003;16(2):114-122. doi:10.1046/j.1529-8019.2003.01620.x
11. Grossbart TA, Sherman C. Skin Deep: A Mind/Body Program for Healthy Skin. Albuquerque, NM: Health Press NA Inc; 1992.