Acute pain management in dermatology

Perioperative pain perception in patients undergoing dermatologic surgery with local anesthesia - A prospective observational study

BACKGROUND

Dermatosurgical procedures are predominantly performed under local anesthesia, yet there are few studies on perioperative pain management for extensive or staged procedures under local anesthesia. The purpose of this study was to assess pain during dermatologic surgery, describe perioperative pain management, and identify factors that influence pain perception.

PATIENTS AND METHODS

This prospective, monocentric study included inpatients undergoing dermatologic surgery under local anesthesia from April to December 2021. Preoperative demographic data, a pain questionnaire, and four psychometric questionnaires (PCS, LOT-R, SFQ, PHQ-9) were collected. Postoperative pain and analgesic use during the first 24 hours were recorded.

RESULTS

A total of 120 patients (with a total of 191 interventions) were included in the study. Mean postoperative pain was reported to be very low (NRS < 2). Preoperative pain and expected postoperative pain were found to be predictive of postoperative pain. There was a strong correlation between catastrophizing and preoperative anxiety (r = 0.65) and a moderate correlation between depression and preoperative anxiety (r = 0.46).

CONCLUSIONS

Dermatologic surgery under local anesthesia is generally considered painless. During preoperative counseling and assessment, attention should be paid to patients who fear surgery, report pain, or anticipate postoperative pain, as they have an increased risk of experiencing postoperative pain.

Perioperative pain management in dermatosurgery - current practice in Germany: Data analysis of a Germany-wide online survey among dermatosurgeons

BACKGROUND

Adequate pain management should be part of the standard of care in surgical procedures. However, there is a paucity of data in the field of dermatosurgery. In a standardized online survey among dermatosurgeons working in Germany, the current practice of perioperative pain management was investigated.

METHODS

Members of the German Society for Dermatosurgery (DGDC) and heads of dermatosurgical departments were asked to participate. Questions were related to practical implementation of perioperative pain management, pain documentation and personal sources of information on the topic.

RESULTS

116 questionnaires were analyzed. While prophylactic analgesia is rarely used, the vast majority (86%) reported the use of postoperative on-demand medication. The majority of surgeons do not have a fixed regimen. Mostly NSAIDs and occasionally low potency opioids are used. Pain is documented by the majority (59.1%) as free text. Personal experience (69%) and in-house standards (51%) are the most important factors in pain management. The use of guidelines (25%) plays a minor role.

CONCLUSIONS

Perioperative pain management in dermatosurgery is strongly influenced by personal experience and may vary depending on the surgery performed. Consensus-based standardized recommendations are lacking. For adequate perioperative analgesia, the development of demand-oriented pain concepts is desirable. This requires prospective studies that address the specific patient population and surgical procedures in dermatology.

Perioperative Schmerztherapie bei dermatochirurgischen Eingriffen - aktuelle Praxis in Deutschland: Datenauswertung einer deutschlandweiten Online-Umfrage unter Dermatochirurgen

Hintergrund

Adäquate Schmerztherapie sollte bei operativen Eingriffen zum regelhaften Behandlungskonzept gehören. In der Dermatochirurgie gibt es hierzu jedoch kaum Daten, wie am besten vorgegangen werden sollte. In einer standardisierten Online‐Umfrage unter in Deutschland tätigen Dermatochirurgen wurde die gängige Praxis der perioperativen Schmerztherapie bei dermotochirurgischen Eingriffen erhoben.

Methodik

Mitglieder der Deutschen Gesellschaft für Dermatochirurgie (DGDC) sowie Leiter dermatochirurgischer Abteilungen wurden um Teilnahme gebeten. Fragen bezogen sich auf praktische Umsetzung des perioperativen Schmerzmanagements, Schmerzdokumentation und persönliche Informationsquellen zum Themenkomplex.

Ergebnisse

116 Fragebögen konnten ausgewertet werden. Während prophylaktische Analgesie kaum angewandt wird, berichtet die überwiegende Mehrzahl (86%), eine postoperative Bedarfsmedikation einzusetzen. Feste Therapieregime existieren mehrheitlich nicht. Zumeist werden NSAR und gelegentlich niedrigpotente Opioide verwendet. Schmerzen werden von der Mehrzahl (59,1%) als Freitext dokumentiert. Die größte Bedeutung beim schmerztherapeutischen Management besitzen persönliche Erfahrungswerte (69%) und hausinterne Standards (51%). Die Nutzung von Leitlinien (25%) spielt eine untergeordnete Rolle.

Schlussfolgerungen

Perioperatives Schmerzmanagement in der Dermatochirurgie ist stark von persönlichen Erfahrungswerten geprägt und kann je nach durchgeführtem Eingriff unterschiedlich ausfallen. Konsensbasierte standardisierte Empfehlungen hierfür fehlen. Für eine suffiziente perioperative Analgesie ist die Entwicklung bedarfsorientierter Schmerzkonzepte wünschenswert. Dafür bedarf es prospektiver Studien, die das spezielle Patientenklientel und operative Vorgehen in der Dermatologie berücksichtigen.

Pain Management in Dermatology

BACKGROUND

The dermatologist has to deal with many situations where the patient feels pain and must therefore know how to manage it.

SUMMARY

The aim of this review was to explore the treatments available to manage pain in dermatology in different circumstances, with an emphasis on pharmacological and non-pharmacological interventions specifically studied in dermatology.

Dermatological Conditions Inducing Acute and Chronic Pain

Pain is a common condition in dermatology. The aim of this review is to analyse the characteristics of pain in dermatology. Some skin diseases are conventionally known to cause pain; e.g. ulcers, pyoderma gangrenosum and herpes zoster. Common dermatoses, such as psoriasis or atopic dermatitis, can also cause significant pain. Some conditions are characterized by neuropathic pain and/or pruritus, without visible primary lesions: e.g. the neurocutaneous diseases, including small fibre neuropathies. Patients often fear pain in skin surgery; however, surgical procedures are rather well tolerated and any pain is mainly due to administration of local anaesthetic. Some therapies may also be uncomfortable for the patient, such as photodynamic therapy or aesthetic procedures. Thus, pain in dermatology is common, and its aetiology and characteristics are very varied. Knowledge of the different situations that cause pain will enable dermatologists to propose suitable analgesic solutions.

Modification of Skin Flaps for Single-Stage Reconstruction of the Nasal Ala Using All-Layer Suture-A Prospective Study

BACKGROUND AND OBJECTIVES

After local flaps, it may be necessary to reconstruct the contour of the nasal ala. This is possible with a single-stage all-layer shaping suture. In the present study, the functional and aesthetic results after single-stage reconstruction of the nasal ala were prospectively evaluated.

PATIENTS AND METHODS

Patients who underwent surgery for skin tumors of the nose between 06/2019 and 06/2020 who required reconstruction of the nasal ala as part of the defect closure and had an all-layer suture used were prospectively included in the study. A standardized evaluation of aesthetic and functional outcome was conducted by the patient and a physician at discharge as well as 4 weeks later. Patients additionally underwent a follow-up survey 6 months later.

RESULTS

Thirty-seven patients were included in the study. Four weeks postoperatively, all flaps were found to be fully healed and vital. Aesthetic outcome at 4 weeks was rated as very good or good by physicians in 73% and by patients in 78.4%. Persistent complications due to reduced blood flow were not observed.

CONCLUSION

The reshaping of the nasal ala as part of the defect reconstruction with an all-layer suture demonstrates very good aesthetic as well as functional results and can be performed in a single-stage procedure. .

Effect of immersive virtual reality on pain in different dental procedures in children: A pilot study

BACKGROUND

Implementing effective pain management is important to increase patient compliance during paediatric dental procedures.

AIM

This pilot study was conducted to evaluate the effectiveness of virtual reality (VR) on pain perception in dental procedures in children.

MATERIAL AND METHODS

Fifty-four children aged between 5 and 12 years were included. Patients scheduled to receive dental procedures not requiring local anesthesia (eg, fluoride therapy) were assigned to Group A, and patients scheduled to receive painful dental procedures requiring local anesthesia (eg, pulp therapy, teeth extraction) were assigned to Group B. Patients in each group were randomly assigned and were equally likely to either receive VR during their dental procedure, or treatment as usual (without VR). Visual analog scale (VAS), Wong-Baker FACES rating scale, and the 'Face, Legs, Activity, Cry, Consolability' scale (FLACC scale) were used to assess the pain levels during dental procedures.

RESULTS

Patients receiving painful dental procedures requiring local anesthesia reported significant reductions in pain intensity/worst pain during the dental procedure on all subjective and behavioral pain measures of pain intensity with the use of VR distraction technique (P < .05 on each). Patients receiving non-painful dental procedures showed the predicted pattern but no significant reduction in worst pain during VR.

CONCLUSION

The use of VR was found to be an effective distraction tool to ease pain and anxiety in the tested dental procedures, for children receiving painful dental procedures.

Pain Intensity Assessment Scales for Dermatologic Surgery Patients: A Systematic Review

BACKGROUND

Pain assessment plays an important role in dermatologic surgery. The numeric rating scale (NRS), visual analog scale (VAS), verbal rating scale (VRS), and Faces Pain Scale (FPS) are commonly used scales for pain measurement. Conflicting evidence exists regarding the use of each. Prompt pain recognition and treatment during procedures result in higher patient satisfaction.

OBJECTIVE

Determine the most applicable scale for acute pain measurement in dermatologic surgery.

MATERIALS AND METHODS

This systematic review was performed in accordance with PRISMA-Supplemental Digital Content 4, http://links.lww.com/DSS/A976 (PROSPERO; CRD42018091058). PubMed, Cochrane, EMBASE, Scopus, and Web of Science were searched between April 24, 2018, and May 06, 2018. The search query consisted of pain, pain measurement (NRS, VAS, VRS, and FPS), and assessment/comparison. The inclusion criteria included English language literature with primary/secondary outcome objectives directly comparing ≥2 pain scales in acute pain (age: 13+). Study end points included interscale correlations, patient preferences, provider preferences, study author recommendations, and failure rates.

RESULTS

Eight hundred seven studies were retrieved: A total of 42 studies were included. The visual analog scale (n = 42) was most studied, followed by NRS (n = 29), VRS (n = 27), and FPS (n = 11). 93.1% studies showed a high statistical correlation between VAS and NRS. Patients preferred NRS (n = 8/11), followed by FPS (n = 3/11), VRS (n = 2/11), and VAS (n = 1/11). Study authors recommended NRS/VAS (n = 8/19), VRS (n = 6/19), and FPS (n = 1/19). Providers preferred NRS (n = 2/3) and VRS (n = 1/3). The visual analog scale had the highest failure rate (n = 11/12).

CONCLUSION

The numeric rating scale is most applicable for dermatologic surgery because of reported patient and provider preferences, lowest failure rates, and most frequent study author recommendations.

Rates of Opioid Prescriptions Obtained After Mohs Surgery: A Claims Database Analysis From 2009 to 2020

Importance

To curtail the opioid epidemic, physicians have been advised to limit opioid prescriptions.

Objective

To characterize the frequency and changes over time (2009-2020) of opioid prescriptions following Mohs micrographic surgery.

Design, Setting, and Participants

This cross-sectional study using Optum Clinformatics DataMart (Optum CDM), a nationally representative insurance claims database, included patients aged 18 years and older who had Mohs micrographic surgery insurance claims in the Optum CDM database from 2009 to 2020. Data were analyzed from November 11, 2020, to March 30, 2021.

Exposures

Opioid prescription following Mohs surgery.

Main Outcomes and Measures

The primary outcome was the proportion of patients who underwent Mohs surgery and obtained an opioid prescription within 2 days of surgery. Secondary outcomes included type and opioid quantity prescribed.

Results

Among 358 012 patients with Mohs micrographic surgery claims (mean [SD] age, 69 [13] years; 205 609 [57.4%] were men), the proportion of patients obtaining an opioid prescription after Mohs micrographic surgery increased from 2009 (34.6%) to 2011 (39.6%). This proportion then declined each year, reaching a low of 11.7% in 2020 (27.9% absolute decrease from 2011 to 2020). Hydrocodone, codeine, oxycodone, and tramadol were the 4 most commonly prescribed opioids. By 2020, hydrocodone was obtained less (2009: 47.5%; 2011: 67.1%; 2020: 45.4%; 21.7% absolute decrease from 2011 to 2020) and tramadol was obtained more (2009: 1.6%; 2020: 27.9%; 26.3% absolute increase from 2009 to 2020).

Conclusions and Relevance

In this cross-sectional study of Mohs micrographic surgery claims, patients obtained fewer postsurgery opioid prescriptions over the study period, suggesting responsiveness of patients and dermatologic surgeons to public health concerns regarding the opioid epidemic. During this decline, prescriptions for hydrocodone decreased and tramadol increased.

Postoperative Pain After Mohs Micrographic Surgery is Well Tolerated Regardless of Psychological and Pain-Related Comorbidities

BACKGROUND

Preoperative patient screening has been evaluated in many surgical specialties as a way to improve the overall patient experience. Current data are limited regarding patient screening for dermatologic procedures. The goal of preoperative screening is to identify patients at risk for poor outcomes and tailor the treatment plan to ensure a greater overall patient experience.

OBJECTIVE

To investigate the association between psychological comorbidities and acute postoperative pain in patients treated with Mohs micrographic surgery (MMS).

MATERIALS AND METHODS

Subjects were recruited from a single center, single provider, uniformed service MMS practice, and asked to complete preoperative and postoperative questionnaires for scheduled MMS. Outcome variables included anticipated pain, actual pain after MMS, duration of pain, and medications used for pain.

RESULTS

Mohs micrographic surgery was well tolerated. There were no significant differences in anticipated or reported pain, or in medication use between cohorts. Significant differences in pain were noted with closure technique with complex surgical repairs generating the greatest pain across groups.

CONCLUSION

Mohs micrographic surgery is well tolerated by patients, both with and without psychological comorbidities. Our results show no statistically significant differences, suggesting a limited role for preoperative screening as a tool to guide pain management after MMS.

Postoperative Pain After Mohs Surgery: Physician Perceptions and How Those Perceptions Influence Opioid Prescribing Practices

BACKGROUND

Little is known about dermatologists' perceptions of postoperative pain and how those perceptions correlate with patient-reported pain and opioid prescribing.

OBJECTIVE

To determine dermatologists' accuracy in predicting postoperative pain compared with patient-reported pain and how physicians' perceptions affect opioid prescribing practices.

METHODS AND MATERIALS

A prospective observational study in which patients undergoing Mohs surgery rated pain on the Numerical Rating Scale (0-10). Using the same scale, the physician predicted how much pain the patient would experience postoperatively on the evening of surgery. All analgesic medications taken in postoperative period were recorded.

RESULTS

A total of 316 patients completed the study (70% completion rate). Physician predictions were correlated with patient-reported pain (p < .001; r = 0.29) and were within 2 points of patient-reported pain in 70% of cases. When physicians overestimated patient-reported by ≥3 points, they were not more likely to prescribe opioids (p = .8094). Physicians predicted higher pain for patients who were prescribed opioids (p = .0002).

CONCLUSION

Dermatologists were fairly accurate at predicting postoperative pain. Dermatologists were not more likely to prescribe opioids when pain was overpredicted.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

Dermatologists are increasing their use of non-opioid pain medications faster than opioids

INTRODUCTION

There is a lack of consensus in the literature on how and when dermatologists should prescribe pain medications. As there is an ongoing opioid abuse epidemic driven by prescription opioids, it is important for all fields to investigate their own prescribing patterns.

METHODS

We analyzed the National Ambulatory Medical Care Survey from 2007 to 2016 to assess the usage of systemic pain medications amongst dermatologists.

RESULTS

There were 16,777 total visits with dermatologists which represents 368 (95% confidence interval 363, 373) million estimated visits. Opioids were used at 1.4% (1.3, 1.6) of visits. As relative proportions, opioids were 35.6 (31.7, 39.6) of all systemic pain medication and non-opioids were 64.4% (53.8, 74.9). The use of opioid (p=.01 [odds ratio 1.08 (1.02, 1.14)]) and non-opioid (p<.001 [odds ratio 1.12 (1.07, 1.17)]) medications increased over the study interval.

CONCLUSION

Pain medications were used at a relatively small proportion of visits with dermatologists. Opioids were nearly half of all pain medications used. The use of opioids and non-opioids rose over the study interval, however, non-opioids rose at a faster rate. The faster rise of non-opioids may indicate that dermatologists are making an effort to use medications with less potential for abuse.

Variability in Wound Care Recommendations Following Dermatologic Procedures

BACKGROUND

Dermatologists routinely perform office-based surgical procedures that result in cutaneous wounds. Wound care instructions are an important resource for postoperative patients. As there is no consensus on the ideal wound care regimen after dermatologic procedures, recommendations may vary.

OBJECTIVE

To evaluate the current recommendations for wound care following dermatologic procedures.

METHODS

The authors conducted a cross-sectional assessment of dermatology wound care handouts available online. The handouts were evaluated based on predefined parameters: topical agent recommendations for wound healing, caution against topical antibiotic use, and discussion of scarring, infection, bleeding, analgesia, and lifestyle considerations.

RESULTS

A total of 169 handouts were evaluated. The majority (84%) recommended the application of petrolatum-based products, specifically Vaseline (75%) and Aquaphor (43%). Nearly half (43%) recommended the use of topical antibiotics, whereas 24% advised patients to avoid antibiotic ointments. Handouts variably addressed scarring (36%), infection (72%), bleeding (69%), pain (66%), and lifestyle modifications (64%).

CONCLUSION

The instructions provided in dermatology patient handouts are highly variable, with various topical agents being recommended for wound healing. Topical antibiotics are not indicated for prophylaxis in clean dermatologic procedures but are still widely used. Greater efforts should be made to ensure that patients receive consistent and evidence-based wound care guidance.

Inhibition of Fast Nerve Conduction Produced by Analgesics and Analgesic Adjuvants-Possible Involvement in Pain Alleviation

Nociceptive information is transmitted from the periphery to the cerebral cortex mainly by action potential (AP) conduction in nerve fibers and chemical transmission at synapses. Although this nociceptive transmission is largely inhibited at synapses by analgesics and their adjuvants, it is possible that the antinociceptive drugs inhibit nerve AP conduction, contributing to their antinociceptive effects. Many of the drugs are reported to inhibit the nerve conduction of AP and voltage-gated Na⁺ and K⁺ channels involved in its production. Compound action potential (CAP) is a useful measure to know whether drugs act on nerve AP conduction. Clinically-used analgesics and analgesic adjuvants (opioids, non-steroidal anti-inflammatory drugs, ₂-adrenoceptor agonists, antiepileptics, antidepressants and local anesthetics) were found to inhibit fast-conducting CAPs recorded from the frog sciatic nerve by using the air-gap method. Similar actions were produced by antinociceptive plant-derived chemicals. Their inhibitory actions depended on the concentrations and chemical structures of the drugs. This review article will mention the inhibitory actions of the antinociceptive compounds on CAPs in frog and mammalian peripheral (particularly, sciatic) nerves and on voltage-gated Na⁺ and K⁺ channels involved in AP production. Nerve AP conduction inhibition produced by analgesics and analgesic adjuvants is suggested to contribute to at least a part of their antinociceptive effects.

Effect of a Vibratory Anesthetic Device on Pain Anticipation and Subsequent Pain Perception Among Patients Undergoing Cutaneous Cancer Removal Surgery: A Randomized Clinical Trial

Importance

Vibration has been shown to decrease injection site pain in patients; however, to date, this effect has not been assessed for patients who catastrophize pain (ie, patients who anticipate a higher pain level). The anticipation of a pain score greater than 4 on the 11-point Numeric Rating Scale (NRS) has been associated with an increase in a patient's perception of procedural pain.

Objective

To assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain (NRS score >4) and patients who do not (NRS score ≤4).

Design, Setting, and Participants

Randomized, parallel-group clinical trial from June 19 to September 4, 2018, at a tertiary dermatologic surgery clinic among 87 adults undergoing cutaneous cancer removal surgery. Patients completed a preprocedural questionnaire detailing their baseline pain, anticipated pain, and drug use. Analysis was performed on an intent-to-treat basis.

Interventions

Use of a vibratory anesthetic device (VAD) on the treatment site prior to anesthetic injection in the on (VAD ON) or off (VAD OFF) mode.

Main Outcomes and Measures

Pain was reported using the 11-point NRS (where 0 indicates no pain and 11 indicates the worst pain imaginable). A minimum clinically important difference of 22% or more and a substantial clinically important difference of 57% or more were used to assess the efficacy of vibration in patient-reported NRS score during anesthetic injection (iNRS score).

Results

A total of 87 patients were included, with 101 unique events reported (among the unique events, 37 were reported in women and 64 were reported in men; mean [SD] age, 66.0 [11.3] years). The mean (confidence level [CL]) iNRS score for patients who catastrophized pain was 2.27 (0.66) compared with 1.44 (0.39) for patients who did not (P = .03). A 38.9% decrease in mean (CL) iNRS score was reported with VAD ON compared with VAD OFF in all participants (1.24 [0.38] vs 2.04 [0.54]). Patients who catastrophized pain reported a 25.5% decrease in mean (CL) iNRS score with VAD ON vs VAD OFF (1.91 [0.99] vs 2.57 [0.98]), and patients who did not reported a 79.4% decrease (1.02 [0.40] vs 1.84 [0.66]). VAD ON was the only statistically significant variable to affect iNRS score (F statistic, 2.741; P = .03).

Conclusions and Relevance

This trial demonstrates that those who catastrophize pain prior to a procedure report a higher perceived level of pain. The application of vibration during local anesthetic injection resulted in a minimum clinically important difference in pain level for patients who catastrophize pain and a substantial clinically important difference in pain level for patients who do not.

Level of Evidence

2.

Trial Registration

ClinicalTrials.gov identifier: NCT03467685.

Differential Analgesia From Vibratory Stimulation During Local Injection of Anesthetic: A Randomized Clinical Trial

BACKGROUND

Inadequate pain reduction during anesthetic injection is a significant medical and surgical problem. Vibratory distraction reduces this pain; however, there are minimal data identifying those who respond best.

OBJECTIVE

To quantify analgesia from vibration before anesthetic injection.

MATERIALS AND METHODS

In this partially blinded, single-institution trial, adult participants were randomized to intervention (vibratory anesthetic device, VAD ON) or placebo (VAD OFF). Pain was assessed using the 11-point numeric rating scale (NRS). Relative reduction in NRS between VAD OFF and ON was used to identify minimum clinically important and substantially clinically important difference in pain.

RESULTS

One hundred one tested sites from 87 subjects were assessed. Sixty-three percent were men with a median age of 66 years. From univariate analysis, males, subjects aged <60, and head and neck (HN) treated subjects had a significant reduction in NRS (p < .05). Multivariate analysis identified NRS reductions in females <60 (p = .012), males ≥70 (p = .002), females and males treated on HN (p = .048 and p = .035, respectively), and males ≥70 treated on HN (p = .012). Substantially clinically important difference (≥57% NRS reduction) included subjects <60, females <70, HN treatment aged 60 to 69, males ≥70, and females treated on HN.

CONCLUSION

Vibratory anesthetic device reduces pain during anesthetic injection, primarily for HN treatments and older male subjects.

Management of keratinocyte carcinoma - Special considerations in the elderly

Keratinocyte carcinomas (KCs) are now an epidemic in The United States of America, especially in elderly patients. KCs, including basal cell carcinoma and squamous cell carcinoma, can lead to disfigurement and occasionally death. However, the lower mortality rate associated with KC compared with melanoma allows for increased flexibility in the selection of treatment. Flexibility in treatment is particularly important in the elderly given that this patient population often has medical comorbidities that should be considered. These patients may have multiple KCs, higher risk tolerance to recurrence, and different concerns about cosmetic outcomes compared with their younger counterparts. We review treatment options for KCs and how the selection of each option may affect the elderly patient.

Dermatologic Surgeons Can Positively Impact the Opioid Epidemic: A Quality Improvement Study of Pain Management in Dermatology Surgery

BACKGROUND

The opioid epidemic is a national emergency, and it is imperative that all physicians are engaged in reducing exposure. Among dermatologists, dermatologic surgeons prescribe most opioids with the highest rates of prescription occurring in Southern states.

OBJECTIVE

Implement a quality improvement intervention to decrease opioids prescribed and filled to <10% of surgeries performed and have a 0% increase in the amount of patient complaints regarding postoperative pain.

MATERIALS AND METHODS

The number of opioids prescribed and filled in a single surgical facility in Georgia was obtained from the state's Prescription Drug Monitoring Program before, 1 month after, and 6 months after implementation of the quality improvement initiative. Telephone encounters regarding postoperative pain was also collected at the same specified periods.

RESULTS

Proportion of opioids prescribed and filled decreased from 58% to 5% at 1-month postintervention and remained low on 6-month follow-up at 4%. There was no increase in postoperative pain complaints. Rather, a decrease in complaints was noted from 8.6% to 3.1% at 1-month postintervention and sustained on 6-month follow-up at 4.9%.

CONCLUSION

Our data support the management of postoperative pain with nonopioid medications.

Characteristics of Opioid Prescriptions by Mohs Surgeons in the Medicare Population

BACKGROUND

Prescription opioid use often precedes opioid misuse, abuse, and addiction.

OBJECTIVE

To characterize the national opioid prescription practices of Mohs surgeons, with general dermatologists serving as a comparison group.

METHODS

A retrospective cross-sectional study using Medicare prescription data to analyze opioid prescription characteristics.

RESULTS

In 2014, 2,190 Mohs surgeons prescribed a total of 86,526 opioids, whereas 10,347 non-Mohs dermatologists prescribed 45,033 opioids. Among Mohs surgeons, 51.8% prescribed more than 10 opioids, whereas 93.3% of non-Mohs dermatologists prescribed 0 to 10. The estimated opioid prescription rates for Mohs surgeons and non-Mohs dermatologists were 5.9% and 0.7%, respectively. Among those prescribing at least 10 opioid claims, the mean number of opioids supplied and mean opioid prescription rate was 72.4 and 13.5, respectively, for Mohs surgeons versus 32.5 and 5.1 , respectively, for non-Mohs dermatologists. The mean days' supply of opioids was 3.9 for Mohs surgeons versus 7.9 for non-Mohs dermatologists. There was a minimal-to-moderate association between the number of procedures performed and the number of opioids prescribed. Men and Mohs surgeons located in southern states tend to prescribe a greater number of opioids.

CONCLUSION

Mohs surgeons prescribed short courses of opioids and less than both the national average and providers that care for patients in pain.

Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population

Importance

The ongoing opioid epidemic in the United States has been fueled by prescription opioids. Increases in opioid-related deaths and complications mandate clinicians in all fields to scrutinize their prescribing patterns.

Objective

To characterize the current status and potential complications of opioid prescribing practices among dermatologists for Medicare beneficiaries.

Design, Setting, and Participants

A cross-sectional study used Medicare Part D prescriber data to evaluate opioid prescriptions by dermatologists from January 1 to December 31, 2014. The number of prescribers, opioid claims, beneficiaries, and days supplied as well as the type of opioid and geographic location of prescribers were extracted and analyzed. The top 1% of dermatologists prescribing opioids were identified and compared with a random sample of the same size among the remaining dermatologists based on sex, geographic location, type of practice, and time in practice. A systematic literature review was conducted to estimate the outcome of opioid prescribing practices on the exposed population.

Main Outcome and Measures

Practice characteristics, epidemiologic factors, and consequences of opioids prescribed by dermatologists.

Results

Of the 12 537 dermatologists in the study, 5305 (42.3%) prescribed no opioid claims, 5408 (43.1%) prescribed 1 to 10 opioid claims, and 1824 (14.5%) prescribed more than 10 opioid claims. Among dermatologists prescribing at least 10 opioid claims, a mean of 1.0 opioid claims was given to each beneficiary, with a supply lasting a mean of 4.4 days. A total of 108 dermatologists (93.9%) in the top 1% of opioid prescribers (n = 115) work in a surgical practice. Estimates suggest that opioids prescribed by dermatologists could annually lead to 3877 to 7602 beneficiaries continuing to use opioids at 1 year and 1825 to 4209 continuing to use opioids at 3 years. A total of 9882 to 22 806 beneficiaries could experience gastrointestinal tract or central nervous system adverse effects and 588 to 999 could experience fractures.

Conclusions and Relevance

Opioid prescribing among dermatologists is limited and concentrated in the surgical setting, but it may be associated with a substantial number of adverse events that serve as a reminder to emphasize nonopioid pain medications in the postoperative setting.

Patient-Centered Care in Dermatologic Surgery: Practical Strategies to Improve the Patient Experience and Visit Satisfaction

Patient-centered care in dermatologic surgery emphasizes addressing the preferences, values, and concerns of the surgical patient in an effort to improve the overall experience. Impediments affecting the delivery of Mohs micrographic surgical treatment of skin cancers are present throughout the perioperative period. Defining actionable strategies to improve outcomes can be challenging due to sparse literature and minimal high-quality scientific studies. This review focuses on the current evidence supporting practical recommendations in each surgical setting to improve the patient experience and increase visit satisfaction.

Efficacy of Microneedling Versus Fractional Non-ablative Laser to Treat Striae Alba: A Randomized Study

BACKGROUND

Striae distensae (SD), an unsightly cutaneous condition characterized by epidermal atrophy, can affect the quality of life of women.

OBJECTIVES

The aim of our study was to compare the efficacy of a neodymium:yttrium-aluminum-perovskite 1340 nm non-ablative fractional laser (NAFL) and the microneedling (MN) technique to treat striae alba (SA).

MATERIALS AND METHODS

NAFL and MN were used to treat striae on the longitudinally divided abdominal surface of 20 women classified as Fitzpatrick skin type III or IV (five sessions at monthly intervals). Photographs and skin biopsies were obtained during pretreatment and after the third and fifth treatment sessions for all patients. Patients and two independent evaluators assessed the clinical response using the Global Aesthetic Improvement Scale.

RESULTS

Patient-reported evaluation showed improvement of striae using both modalities, with no statistically significant difference between the groups. Collagen and elastic fibers were significantly increased (p < 0.01) after the third and fifth treatment sessions, with no significant difference between the modalities. In addition, Dermatology Life Quality Index scores showed significant improvement (p < 0.001) after the third and fifth treatment sessions compared with pretreatment values, with average values of 8.4 (standard error [SE] ± 1.21), 3.17 (SE ± 0.55), and 2.64 (SE ± 0.60), respectively. The mean pain score using the Visual Analog Scale in the MN group versus the NAFL group was 5.23 (SE ± 0.31) versus 2.39 (SE ± 0.22) [p < 0.001], and the mean duration of adverse events in the NAFL group versus the MN group was 4.03 days (SE ± 0.45) versus 3 days (SE ± 0.37) [p = 0.02].

CONCLUSION

NAFL and MN are safe for treating SD, particularly in individuals classified as phototype III or IV. MN is a useful non-technology-dependent, low-cost alternative therapy for SA.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03390439.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery

BACKGROUND

Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS).

OBJECTIVE

We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS.

MATERIALS AND METHODS

A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls.

RESULTS

Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure.

CONCLUSION

This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

The perception of procedural vascular laser pain and discrepancies amongst patients, physicians, and industry

BACKGROUND

The inherent subjectivity of pain perception makes pre-procedural pain counseling especially challenging. Setting the wrong pain expectations will negatively impact the patient's experience and affect their physiologic and emotional state. Best practices for sourcing pain related information about a given procedure, however, remains understudied. This retrospective study explores the accuracy of industry materials for describing procedural pain in a clinical trial when compared to subject reported pain scores from the same clinical trial.

METHODS

Median and mode pain scores were collected from the data of a past clinical trial investigating a dual wavelength laser used for 4 different types of treatments. Industry provided materials were reviewed to ascertain language regarding procedural pain. The principal investigator was interviewed about setting pain expectations during the trial. Subject-reported pain scores and verbal pain descriptors were transferred to validated pain scales, the Numerical Rating Scale and the Verbal Rating Scale, for comparison.

RESULTS

A total of 85 procedural pain scores were collected from 22 subject charts. The average procedural pain scores for 3 of 4 treatment types reported by subjects were translated to entirely different verbal and numerical categories of pain than that described by industry materials.

CONCLUSIONS

Industry materials failed to capture the range of procedural pain scores reported by subjects for 3 of 4 treatment types in a clinical trial setting. When counseling patients on procedural pain, physicians should take extra care to not mislead patients and cause undue physiological or emotional stress.

Assessment of intraoperative pain during Mohs micrographic surgery (MMS): An opportunity for improved patient care

BACKGROUND

Intraoperative pain during Mohs micrographic surgery (MMS) has not been characterized. However, many patients report postoperative pain on the day of MMS.

OBJECTIVE

We sought to determine if patients experience pain during their MMS visit.

METHODS

In phase I of this study, patients were asked to report intraoperative pain level using the verbal numerical rating scale (0-10) at discharge. In phase II, pain levels were assessed before each Mohs layer and at discharge, to determine whether pain was experienced throughout the day.

RESULTS

Pain was reported at some point during the MMS day for 32.8% of patients (n = 98). The mean pain number reported was 3.7 (range 1-8) out of 10. Pain was more commonly reported by patients who spent a longer time in the office, had 3 or more Mohs layers, and had a flap or graft repair. Patients most frequently reported pain with surgical sites of the periorbital area and nose.

LIMITATIONS

Time between Mohs layers was not measured. There was nonstandardized use of intraoperative local anesthesia volume and oral pain medications.

CONCLUSION

Some patients experience pain during MMS. However, the majority of patients report a low level of pain. Additional preventative measures could be considered in patients at higher risk.