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Conference summaries

Pain management in dermatology

Pain Management in Dermatology

Presented by: Prof. Laurent Misery
Dept. of Dermatology, University Hospital, Brest, France

Pain and itch are two very different things, both of which may be experienced by dermatology patients. While they both provide an unpleasant feeling, they have an important protective function. Itch is usually located in the skin and close mucosa, while pain can be felt anywhere throughout the body. IL-2, IL-13, and IL-31 are traditionally involved in itch, while pain can involve numerous different cytokines. Each also may increase or decrease with cold/heat or types of opioids.

Skin pain may result from any number of issues such as wounds, pressure and leg ulcers, burns, as well as iatrogenic pain and diseases. Chronic pain is also associated with many skin disorders such as atopic dermatitis, psoriasis, reactive skin, and others.

Some of the sensations associated with pain include:1

  • Burning
  • Cold pain sensations
  • Electric shock sensations
  • Tinging
  • Pricking
  • Numbness
  • Itch.

Pain with dermatology conditions signifies a poorly treated disorder. Naturally, pain is a main concern of patients and it must be searched systematically. The patient or caregiver should be questioned, but patients may fear that pain is a result of a worsening pathology. In addition, some patients may have difficulty expressing pain because of psychiatric or functional disorders. Regardless of these issues, pain should be actively treated and systematically prevented.

There are a number of scales that can be used to assess pain. Some of these are listed here:

  • Visual Analogue Scale
  • Word Descriptor Scale
  • Graphic Scale
  • Verbal Scale
  • Functional Pain Scale.

The identification and scale of neuropathic pain is slightly different and a DN4 (Douleur Neuropathique 4 questions) questionnaire is useful to determine the presence of pain. Neuropathic pain may include any of the following sensations; stabbing, pins and needles, throbbing, burning, electric shock-like, numbness, and shooting pains.

There are a number of medications that may be used to treat skin pain. A sampling of these include:

Neuropathic pain

Local anesthetics
  • Injectables
  • Cream
    • Lidocaine + prilocaine (EMLA and generics), possible under occlusive
    • Superficial anesthesia (5 mm)
    • Application <90 minutes before care
Pain killers
  • WHO levels for analgesics
    • Level 1 - mild pain (non-opioid): acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors
    • Level 2 - moderate pain (weak opioid): oxycodone, hydrocodone, tramadol and codeine
    • Level 3 - severe pain (strong opioid): morphine, fentanyl, and hydromorphone
  • Paracetamol
    • Has good tolerance but patients may be allergic
    • Hepatic toxicity if overdose: do not exceed 4 g/day
    • May be associated with codeine
  • NSAIDs (aspirin, ibuprofen and others)
    • Poorly indicated in skin pain
    • Absolute contraindication in skin infections because promotes necrosis
    • Good efficacy
    • Many potential side effects
  • Tramadol
    • 50-400 mg/day per os or intravenous therapy (IV)
    • May cause psychological dependence (use for limited duration)
    • Very good efficiency
    • Side effects: drowsiness, dizziness, nausea, headache, constipation, xerostomia, and hyperhidrosis
  • Opioids
    • Numerous options available
    • Per os, IV, intramuscular injection (IM), subcutaneous administration (SC), spray or patch
    • Excellent efficiency
    • Multiple side effects: physical dependence, drowsiness, dizziness, nausea, headache, constipation, xerostomia, and hyperhidrosis
Anti-epileptics
  • Gabapentin (300-3600 mg/day) and pregabalin (50-600 mg/day)
  • Effective are effective in neuropathic pain
  • Well tolerated
  • Side effects: drowsiness, dizziness, nausea, and headache
Anti-depressants
  • Effects on depression and anxiety
  • Effects on neuropathic pain
Anxiolytics
  • No direct effect on pain
  • Prescription limited in time because of risk of physical dependence (except hydroxyzine)
Nitrous oxide
  • Mixture of equimolar oxygen and nitrous oxide (MEOPA)
  • Entonox, Kalinox, Antasol, and Oxynox
  • Analgesic but especially anxiolytic
  • “Laughing gas”
  • Contraindications: intracranial hypertension, emphysema, and pneumothorax
  • Rare side effects: nausea, excessive agitation or sedation, malaise, and headache
Acupuncture
  • Proven efficiency
  • Performed only by qualified specialists
  • Variants: auriculotherapy, moxibustion, and electroacupuncture
Neurostimulation
  • Electrical or electromagnetic stimulation
  • Transcranial (TMS), transcutaneous (TENS) or percutaneous (PENS)
Psychotherapeutic approach
  • Relaxation, bio-feedback, and yoga
  • Meditation and mindfulness
  • Hypnosis
  • Supportive psychotherapy
  • Analytical psychotherapy

 

The placebo and nocebo effect have been shown to be effective in 30% to 70% of patients with pruritis or pain. The placebo and nocebo effect do not have a known relationship with any underlying psychological disorder.

In a meta-analysis, the placebo effect on itch was systematically investigated in clinical trials including patients with chronic itch due to atopic dermatitis, psoriasis, or chronic idiopathic urticaria.2 Placebo treatment significantly decreased itch, indicating that placebo effect has a considerable role in these patients.3

 

Key messages

  • The prevention and treatment of pain should be addressed with patients.
  • There are a number of medications and different approaches that may be used to help minimize pain.


REFERENCES

Present disclosure: The presenter disclosed that he has worked with A-Derma, Amgen, Biogen, Celgene, and Pfizer.

Written by: Debbie Anderson, PhD

Reviewed by: Victor Desmond Mandel, MD



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