J Clin Aesthet Dermatol. 2025;18(7):22–23.
by Roger I. Ceilley, MD, FAAD, FCMS, and Shandhan Sureshbabu, CDT
Dr. Ceilley is with the Department of Dermatology at the University of Iowa in Iowa City, Iowa. Dr. Ceilley and Mr. Sureshbabu are with Dermatology P.C. in West Des Moines, Iowa.
FUNDING: No funding was provided for this article.
DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.
Abstract: A key strategy for pain management in dermatologic procedures is the use of local anesthesia, yet the injection itself often causes significant discomfort. This article explores evidence-based strategies to minimize pain during anesthetic administration in office-based dermatologic settings. Techniques discussed include buffering and warming lidocaine, selecting the optimal needle gauge, orienting the bevel properly, as well as adopting advanced injection methods such as subdermal bleb formation and parallel needle insertion. Additional methods like tactile distraction, hand stabilization, and psychological engagement are also emphasized. Together, these approaches enhance patient comfort, procedural efficiency, and overall satisfaction with dermatologic care. Keywords: Local anesthesia, dermatologic procedures, pain reduction, lidocaine, injection techniques, patient comfort, psychological considerations, anesthetic administration
Introduction
Local anesthesia is essential in dermatologic surgery to provide pain relief and ensure patient comfort. However, the infiltration of the anesthetic itself is often perceived as the most painful part of minor procedures. Optimizing anesthetic administration through proper technique, solution preparation, and patient engagement can significantly reduce discomfort, improve procedural efficiency, and enhance the overall patient experience.
Solution Preparation: Buffering and Warming for Pain Reduction
Buffering lidocaine with sodium bicarbonate reduces injection pain by increasing the pH of the solution, thereby reducing the burning sensation often associated with acidic anesthetic formulations. Studies have shown that a 1:10 ratio of 8.4% sodium bicarbonate to 1% lidocaine with 1:100,000 epinephrine effectively minimizes discomfort without compromising anesthetic efficacy.1,2
Warming the anesthetic solution to body temperature (37°C) before injection further reduces pain perception, as supported by multiple studies demonstrating its efficacy in reducing discomfort.1,2 The increased solubility of lidocaine at warmer temperatures may also expedite its onset, allowing for faster numbing and improved patient comfort.
Equipment Selection: Needle Gauge and Bevel Orientation
Using smaller gauge needles (27G or 30G) has been consistently shown to reduce pain during local anesthetic injections. Additionally, needle bevel orientation plays a critical role in pain perception. Inserting the needle with the bevel facing up reduces pain compared to a bevel-down orientation.3 This is likely due to the directional flow of anesthetics away from nociceptors, limiting direct stimulation of pain fibers.
Injection Techniques: Minimizing Tissue Trauma
Parallel minimal insertion technique. A novel approach involves inserting the needle parallel to the skin within the superficial dermis, allowing the anesthetic to diffuse gradually before reaching deeper structures. This method significantly decreases pain compared to traditional perpendicular injections.4 Counter traction helps stabilize the site and facilitates easy injections. Injecting through a pore on sebaceous skin is also less painful.
Subdermal bleb formation. Initiating the injection with a small subdermal bleb (0.2–0.5mL) before proceeding with the full infiltration gives time for localized numbness to develop, reducing subsequent pain. Waiting 30 to 45 seconds before continuing the injection ensures optimal analgesia.2
Slow, steady injection. Pain is exacerbated when anesthetic is injected too quickly, causing rapid tissue distension. Slowing the rate of injection to 0.3 to 0.5mL per second reduces mechanical pain and allows the anesthetic to disperse more evenly.2
Tactile distraction techniques. Applying counter-pressure, pinching the skin, or using vibration near the injection site activates larger, fast-conducting nerve fibers that inhibit pain signal transmission through the gate control mechanism.2 This simple maneuver can significantly reduce patient discomfort.
Hand stabilization during injection. To minimize needle movement and reduce patient discomfort, stabilizing the syringe-holding hand is crucial. Unsteady needle control can lead to increased pain until the site becomes numb. A simple way to enhance stability is by resting fingers or stacked gauze on the patient’s skin while injecting, similar to techniques used in microsurgery. This approach improves control over the needle level, reducing unintended shifts that could cause additional discomfort. If the syringe is not well-supported, patients may feel even the smallest needle movement until anesthesia takes effect.
Additional Techniques for Pain Reduction
For pediatric patients and those with heightened sensitivity, applying a topical anesthetic (such as a eutectic mixture of local anesthetics [EMLA] cream) before injection can help desensitize the area and minimize discomfort. Similarly, applying ice to the injection site for a few minutes can provide temporary numbing and reduce the initial sensation of pain. Vibration tools, which distract the nerves with mechanical stimulation, have also been shown to lessen pain perception during injections.2
For superficial biopsies, waiting for a blanche to appear (if the anesthetic contains epinephrine) helps ensure there is adequate anesthesia. For superficial procedures such as tangential biopsies, the infiltration should be superficial enough to obtain a peau d’orange (ie, dimpled) appearance to the skin.
In select cases, regional nerve blocks can provide prolonged anesthesia and reduce the need for multiple injections. For procedures involving the nose, ears, or lips, nerve blocks can offer superior pain control and improve patient comfort.2 Proper knowledge of anatomical landmarks and safe injection techniques is essential when performing nerve blocks to ensure effective anesthesia while minimizing complications.
Enhancing Patient Comfort: Psychological Considerations
Engaging with the patient, providing reassurance, and encouraging them to look away during injection can lower anxiety and decrease perceived pain. Distraction techniques, such as conversation or guided breathing exercises, can further improve patient tolerance of the procedure. Verbally guiding the patient through the procedure—explaining each step before performing it, such as wiping with alcohol to clean the area, when the injection will begin, and what sensations they may experience (eg, an initial poke followed by a brief burning sensation)—helps build trust and reduces anxiety.
Conclusion
A well-thought-out approach to local anesthesia administration in dermatologic procedures can minimize pain and enhance patient satisfaction. Optimizing solution preparation, choosing appropriate equipment, and refining injection techniques are key strategies for achieving nearly painless anesthesia. With these evidence-based techniques, dermatologic surgeons can improve procedural outcomes while ensuring a more comfortable experience for their patients.
References
- Zaiac M, Aguilera SB, Zaulyanov-Scanlan L, et al. Virtually painless local anesthesia: diluted lidocaine proves superior to buffered lidocaine for subcutaneous infiltration. J Drugs Dermatol. 2012;11(10):e39–e42.
- Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132(3):675–684.
- Candiotti K, Rodriguez Y, Koyyalamudi P, et al. The effect of needle bevel position on pain for subcutaneous lidocaine injection. J Perianesthes Nurs. 2009;24(4):241–243.
- Zelickson BR, Goldberg LH, Rubenzik MK, et al. Parallel, minimal needle-insertion technique for achieving a painless injection of local anesthetic. J Am Acad Dermatol. 2017;77(2):369–370.
- Finsen V. Reduced pain when injecting lidocaine. Tidsskr Nor Laegeforen. 2017;137(9):629–630.
Optimizing Local Anesthesia Use in Office-based Dermatologic Procedures
Categories:
J Clin Aesthet Dermatol. 2025;18(7):22–23.
by Roger I. Ceilley, MD, FAAD, FCMS, and Shandhan Sureshbabu, CDT
Dr. Ceilley is with the Department of Dermatology at the University of Iowa in Iowa City, Iowa. Dr. Ceilley and Mr. Sureshbabu are with Dermatology P.C. in West Des Moines, Iowa.
FUNDING: No funding was provided for this article.
DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.
Abstract: A key strategy for pain management in dermatologic procedures is the use of local anesthesia, yet the injection itself often causes significant discomfort. This article explores evidence-based strategies to minimize pain during anesthetic administration in office-based dermatologic settings. Techniques discussed include buffering and warming lidocaine, selecting the optimal needle gauge, orienting the bevel properly, as well as adopting advanced injection methods such as subdermal bleb formation and parallel needle insertion. Additional methods like tactile distraction, hand stabilization, and psychological engagement are also emphasized. Together, these approaches enhance patient comfort, procedural efficiency, and overall satisfaction with dermatologic care. Keywords: Local anesthesia, dermatologic procedures, pain reduction, lidocaine, injection techniques, patient comfort, psychological considerations, anesthetic administration
Introduction
Local anesthesia is essential in dermatologic surgery to provide pain relief and ensure patient comfort. However, the infiltration of the anesthetic itself is often perceived as the most painful part of minor procedures. Optimizing anesthetic administration through proper technique, solution preparation, and patient engagement can significantly reduce discomfort, improve procedural efficiency, and enhance the overall patient experience.
Solution Preparation: Buffering and Warming for Pain Reduction
Buffering lidocaine with sodium bicarbonate reduces injection pain by increasing the pH of the solution, thereby reducing the burning sensation often associated with acidic anesthetic formulations. Studies have shown that a 1:10 ratio of 8.4% sodium bicarbonate to 1% lidocaine with 1:100,000 epinephrine effectively minimizes discomfort without compromising anesthetic efficacy.1,2
Warming the anesthetic solution to body temperature (37°C) before injection further reduces pain perception, as supported by multiple studies demonstrating its efficacy in reducing discomfort.1,2 The increased solubility of lidocaine at warmer temperatures may also expedite its onset, allowing for faster numbing and improved patient comfort.
Equipment Selection: Needle Gauge and Bevel Orientation
Using smaller gauge needles (27G or 30G) has been consistently shown to reduce pain during local anesthetic injections. Additionally, needle bevel orientation plays a critical role in pain perception. Inserting the needle with the bevel facing up reduces pain compared to a bevel-down orientation.3 This is likely due to the directional flow of anesthetics away from nociceptors, limiting direct stimulation of pain fibers.
Injection Techniques: Minimizing Tissue Trauma
Parallel minimal insertion technique. A novel approach involves inserting the needle parallel to the skin within the superficial dermis, allowing the anesthetic to diffuse gradually before reaching deeper structures. This method significantly decreases pain compared to traditional perpendicular injections.4 Counter traction helps stabilize the site and facilitates easy injections. Injecting through a pore on sebaceous skin is also less painful.
Subdermal bleb formation. Initiating the injection with a small subdermal bleb (0.2–0.5mL) before proceeding with the full infiltration gives time for localized numbness to develop, reducing subsequent pain. Waiting 30 to 45 seconds before continuing the injection ensures optimal analgesia.2
Slow, steady injection. Pain is exacerbated when anesthetic is injected too quickly, causing rapid tissue distension. Slowing the rate of injection to 0.3 to 0.5mL per second reduces mechanical pain and allows the anesthetic to disperse more evenly.2
Tactile distraction techniques. Applying counter-pressure, pinching the skin, or using vibration near the injection site activates larger, fast-conducting nerve fibers that inhibit pain signal transmission through the gate control mechanism.2 This simple maneuver can significantly reduce patient discomfort.
Hand stabilization during injection. To minimize needle movement and reduce patient discomfort, stabilizing the syringe-holding hand is crucial. Unsteady needle control can lead to increased pain until the site becomes numb. A simple way to enhance stability is by resting fingers or stacked gauze on the patient’s skin while injecting, similar to techniques used in microsurgery. This approach improves control over the needle level, reducing unintended shifts that could cause additional discomfort. If the syringe is not well-supported, patients may feel even the smallest needle movement until anesthesia takes effect.
Additional Techniques for Pain Reduction
For pediatric patients and those with heightened sensitivity, applying a topical anesthetic (such as a eutectic mixture of local anesthetics [EMLA] cream) before injection can help desensitize the area and minimize discomfort. Similarly, applying ice to the injection site for a few minutes can provide temporary numbing and reduce the initial sensation of pain. Vibration tools, which distract the nerves with mechanical stimulation, have also been shown to lessen pain perception during injections.2
For superficial biopsies, waiting for a blanche to appear (if the anesthetic contains epinephrine) helps ensure there is adequate anesthesia. For superficial procedures such as tangential biopsies, the infiltration should be superficial enough to obtain a peau d’orange (ie, dimpled) appearance to the skin.
In select cases, regional nerve blocks can provide prolonged anesthesia and reduce the need for multiple injections. For procedures involving the nose, ears, or lips, nerve blocks can offer superior pain control and improve patient comfort.2 Proper knowledge of anatomical landmarks and safe injection techniques is essential when performing nerve blocks to ensure effective anesthesia while minimizing complications.
Enhancing Patient Comfort: Psychological Considerations
Engaging with the patient, providing reassurance, and encouraging them to look away during injection can lower anxiety and decrease perceived pain. Distraction techniques, such as conversation or guided breathing exercises, can further improve patient tolerance of the procedure. Verbally guiding the patient through the procedure—explaining each step before performing it, such as wiping with alcohol to clean the area, when the injection will begin, and what sensations they may experience (eg, an initial poke followed by a brief burning sensation)—helps build trust and reduces anxiety.
Conclusion
A well-thought-out approach to local anesthesia administration in dermatologic procedures can minimize pain and enhance patient satisfaction. Optimizing solution preparation, choosing appropriate equipment, and refining injection techniques are key strategies for achieving nearly painless anesthesia. With these evidence-based techniques, dermatologic surgeons can improve procedural outcomes while ensuring a more comfortable experience for their patients.
References
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