Review Article
Dermatology
Dermatology 2023;239:675–684
DOI: 10.1159/000531758
Pain Management in Dermatology
Mathilde Hayoun a Laurent Misery a, b
aDepartment of Dermatology, University Hospital of Brest, Brest, France; bLIEN, University Brest, Brest, France
Keywords
Pain management · Dermatology · Skin disorders · Skin
surgery · Photodynamic therapy
Abstract
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.
© 2023 S. Karger AG, Basel
Introduction
Pain is a frequently encountered problem in der-
matology. A large number of dermatoses are respon-
sible for pain. For example, more than half of patients
suffering from psoriasis or atopic dermatitis (AD)
report pain, often with a neuropathic component [1].
Zoster and postherpetic neuralgia (PHN) are also re-
sponsible for significant, chronic, neuropathic pain.
Chronic lower limb ulcers are responsible for chronic
pain, and there appears to be a neuropathic component
[2]. In addition, ulcer care is also painful for the patient
[3]. Many dermatological procedures are responsible
for acute pain which may limit their use, such as skin
surgery, dynamic phototherapy, botulinum toxin or
filler injections for aesthetic purposes, or botulinum
karger@karger.com © 2023 S. Karger AG, Basel
www.karger.com/drm
Received: November 18, 2022
Accepted: June 23, 2023
Published online: July 11, 2023
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toxin injections at the palmoplantar region to reduce
hyperhidrosis. In this context, it is mainly a question of
preventing the occurrence of pain. The aim of this
review was to explore the treatments available to
manage pain in dermatology in different circum-
stances, with an emphasis on pharmacological and
non-pharmacological interventions specifically studied
in dermatology.
Methods
A PubMed, Cochrane, and Google Scholar search was con-
ducted for papers published since January 1, 2000, using the
following terms: “pain management AND dermatology.” Then,
additional searches were performed on drug interventions and
non-drug alternatives for analgesic treatment (such as hypnosis,
virtual reality, musical interventions, transcutaneous electrical
nerve stimulation) for each circumstance studied. Articles in
languages other than English or French were excluded. The articles
were selected first based on the title and then on the abstract, and
the full text of all potentially relevant articles was retrieved for
detailed evaluation. Reference citations within identified articles
were also examined to ensure that all relevant evidence was
retrieved.
Pain Management in Certain Skin Disorders
Atopic Dermatitis
There is still a lack of evidence to confirm pain relief
from many AD treatments [4]. Most of them have been
shown to be effective in treating pruritus; however, most
treatments for AD have been poorly studied for their
Correspondence to:
Mathilde Hayoun, vigourouxmathilde7 @ gmail.com
effect on skin pain [4, 5]. But pain seems to be a distinct
symptom from itch in AD which significantly impairs
quality of life [6, 7].
Clinical application of common analgesics treatments
in AD patients has not yet been reported [4]. A Danish
study showed that analgesic consumption was not in-
creased in AD patients compared to the general pop-
ulation. Among patients with severe AD, there was a
slightly higher consumption of pregabalin/gabapentin
but not significantly. This supports that skin pain is
probably reduced by adequate AD therapy [8].
A position paper proposed a treatment algorithm for
the management of itch and skin pain in AD patients. It is
based initially on the specific treatments for AD and in
the event of persistent pain on adding a specific pain
treatment (common analgesics, gabapentinoids, antide-
pressants, anti-JAK, anti-PDE4, opioids) [5].
Recently, Silverberg et al. [6] showed, through a post
hoc analysis of 2,632 patients, that dupilumab with or
without topical steroids, alleviates pain/discomfort in a
significantly higher proportion of patients relative to
placebo or topical steroids. The mechanism by which
dupilumab reduces pain in AD is unclear, but dupilumab
has been shown to significantly alleviate inflammatory
skin lesions. Reducing inflammation can lead to lower
levels of inflammatory mediators of pain, and skin in-
tegrity may protect sensory nerve endings against ex-
ternal nociceptive stimuli [6].
Thyssen et al. [9] found that baricitinib allowed rapid
enhancement in patient-reported skin pain in AD from
the first day after first dose administration. This can be
explained because JAK inhibitors modulate gene ex-
pression to restore normal cytokine profiles, which leads
to improve the neuroimmune communication that re-
duces pain [10].
Psoriasis
It has been shown that about half of the patients with
psoriasis report skin pain [1], and this is not directly cor-
related with the severity of the Psoriasis Area Severity Index
(PASI) score [11]. Improvement in psoriasis lesions predicts
the reduction in the intensity of skin pain [11]. Therefore,
treatment of the underlying cause permits pain management
but treating psoriatic lesions alone may be insufficient for
short-term pain. In the absence of official guidelines, relief
options for acute pain may include mild analgesics, such as
acetaminophen, NSAIDs, and mild opiates [12], but they
have not been evaluated specifically in psoriasis.
The efficacy of specific psoriasis treatments is assessed
via various scores, notably the PASI and Physician Global
Assessment (PGA) score, but this does not always capture
676 Dermatology 2023;239:675–684
DOI: 10.1159/000531758
skin pain, so further trials are being conducted to assess
the impact of these treatments on skin pain. A prospective
study shows that calcipotriol plus betamethasone di-
propionate in aerosol foam formulation not only im-
proves skin lesions but also improves skin pain from the
first week of application [13].
In two phase 3 trials, apremilast allowed an 80%
improvement in skin discomfort and pain at week 2 [14].
Some biologic therapies have been studied for their effects
on skin pain. A report demonstrates a significant im-
provement in pain for 70% of patients (n = 820) after
2 weeks of treatment with secukinumab in patients with
moderate-to-severe plaque psoriasis, compared to 48% of
patients on etanercept and 6% on placebo [15]. A study
about three 12-week phase 3 clinical trials shows that
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ixekizumab has statistically significant improvements in
skin compared with etanercept and placebo [16]. Ri-
sankizumab permits significantly lower Psoriasis Symp-
tom Scale (PSS) score, which includes an item on pain
intensity, compared with those in the placebo group at
week 4 [17].
Pemphigus
Pain in pemphigus is poorly studied. Tamasi et al.
show that half of patients report skin pain [18] (N = 109).
There are few studies that specifically address pain
management in patients with pemphigus [19, 20]. In the
absence of specific analgesic management recommen-
dations for pemphigus, the rules laid down by the WHO
apply, i.e., use an analgesic adapted to the intensity of the
pain [21]. In cases of moderate to severe pain (intensity >
or = 4/10 on a numerical scale of 0–10), opioids should be
started immediately [22]. Fentanyl has the added ad-
vantage of being rapidly absorbed across the mucosa and
having a short onset and duration of analgesia [23]. Most
recently, the use of low-level laser therapy on pemphigus-
induced erosions resulted in a decrease in erosion size and
an improvement in pain [24]. Sleep and prevention of
insomnia have also been shown to improve wound
healing and pain and decrease stress-induced cytokine
release [24]. A case report shows the efficacy of topical
ketamine in the treatment of pain in oral pemphigus,
independent of lesion healing [25]. A clinical case report
was done on the efficacy of gabapentin in the treatment of
pain in fentanyl-resistant severe pemphigus vulgaris [26].
Stevens-Johnson Syndrome and Toxic
Epidermal Necrolysis
The management recommendations are similar to
those for burn patients [27], as those patients are indeed
often admitted to the burn unit [28]. Frequent pain
Hayoun/Misery
assessment is necessary [27, 29]. Recommendations for
supportive care have been proposed by the Society of
Dermatology Hospitalists in 2020 [30]. It is proposed that
oral synthetic opiates control moderate pain, and mor-
phine or fentanyl are administered intravenously for
severe pain [30, 31]. It is also possible to use low-dose
ketamine [30]. Gabapentin and pregabalin are useful for
neuropathic pain [30]. For oral involvement, mouth-
washes with lidocaine are recommended for analgesic
purposes, as well as topical coating agents, such as hy-
droxypropyl methylcellulose film-forming agents [30]. A
urinary catheter is inserted to decrease pain during
urination [30]. By analogy to the management of burn
patients, non-drug analgesic methods can be proposed
such as hypnosis, relaxation, distraction media in com-
bination with medicinal methods [32]. Adding an an-
xiolytic to local and general analgesic treatments can
improve anxiety and the perception of acute pain [29].
The use of non-adherent dressings is recommended [27],
and the Society of Dermatology Hospitalists pleads for
preserve detached epidermis as a biologic dressing [30].
One of the most painful moments in the acute phase
remains mobilisation, bathing [29], and dressing care [32]
pain may be controlled by IV opioid analgesics (e.g.,
fentanyl), IV anaesthetic agents (e.g., propofol, ketamine,
dexmedetomidine, lidocaine), oral opioid analgesics (e.g.,
oxycodone, hydromorphone), oral ketamine, oral cloni-
dine, and inhaled nitrous oxide [29, 32]. For more severe
procedural pain, general anaesthesia, deep sedation, or
regional anaesthesia could be necessary [32].
Zoster and PHN
In the acute phase, conventional analgesics can be
prescribed according to European consensus and follow
the three-step WHO pain ladder as based on the severity
of pain, and because of the neuropathic component of
pain, tricyclic antidepressant or antiepileptic drugs (e.g.,
gabapentin, pregabalin) may be added [33]. A small study
(N = 38) found that lidocaine patch 5% was well tolerated
and effective in herpes zoster acute neuralgia with a rapid
pain relief and reducing the use of systemic analgesics
from the second week and could prevent PHN [34]. It is
also effective in PHN [35]. A prospective randomized
controlled trial, about 97 patients with acute thoracic
herpes zoster, showed that a single intra-cutaneous in-
jection of local anaesthetic (ropivacaine) and steroid
(methylprednisolone) resulted in significant lower pain
intensity, shorter pain duration, and decreased course of
skin eruption [36], but results were not significant for
prevention of PHN [36]. Cochrane reviews found that
oral aciclovir does not prevent PHN but permits a re-
Pain Management
duction in the incidence of pain in the short term [37],
and corticosteroids in the acute phase are also ineffective
in preventing PHN [38], neither is gabapentin [39]. A
Korean meta-analysis found that continuous epidural
block, antiviral agents with intra-cutaneous or subcuta-
neous injection with local anaesthetics and steroid, and
paravertebral block combined with antiviral and anti-
epileptic agents would be effective strategies at the acute
phase for preventing PHN [40].
Postherpetic pain is treated as pure neuropathic pain:
amitriptyline, pregabalin, and gabapentin have been
studied specifically in PHN and provides a good pain
relief, with moderate-quality evidence [41–43]. In con-
trast, there is little evidence to support the use of nor-
triptyline and oxcarbazepine in the context of neuro-
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pathic pain, especially as these molecules have been
poorly studied in PHN [44, 45]. But crossover trial
suggests that associate gabapentin and nortriptyline
seems to be more efficacious than either drug alone for
neuropathic pain including PHN, without increasing side
effects [46]. Concerning duloxetine, there is moderate-
quality evidence that it is efficacious for treating pain in
diabetic peripheral neuropathy, but it was not specifically
studied in PHN [47]. High-concentration topical cap-
saicin (8%) is better than very low concentration in
people with PHN and provides a good pain relief for
2–12 weeks after a single application [48]. Small-sample
studies provide emerging evidence of possible effective-
ness of botulinum toxin in the treatment of PHN because
it can inhibit the release of neurotransmitters (glutamate,
substance P, and calcitonin gene-related peptide) and
permit the relief of neuropathic pain [49, 50]. Data are
also emerging on the effectiveness of transcutaneous
electrical nerve stimulation (TENS) in the treatment of
neuropathic pain, based on the fact that TENS activates
nerve fibres and induces the release of the endogenous
opioid, the modification of electrical transmission, and
the dilation of blood vessels [51]. A randomized trial (N =
20) found a significant decrease in pain scores by using
TENS in PHN [52]. However, a Cochrane review is
unable to state the effect of TENS for neuropathic pain
relief due to the very low quality of evidence [53]. Finally,
there is a benefit to vaccination for older adults.
Moderate-quality evidence suggests that among people
aged 60 years and over, vaccines may reduce the incidence
of herpes zoster for at least 3 years after vaccination [54].
Herpes Genitalis
The management of pain in genital herpes is poorly
studied. Aciclovir and valaciclovir can reduce the dura-
tion of symptoms [55]. The 2017 European guidelines
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suggest the use of lidocaine gel but avoid benzocaine,
which has a risk of sensitisation [56]. A study has shown
the analgesic efficacy of barrier genital gel for controlling
pain and time to heal was significantly shorter [57].
Ulcers
Most patients with chronic lower limb ulcers have
permanent pain, which worsens during treatment. Pain
increases cortisol levels, the heart rate, and the blood
pressure, which can hinder healing [58]. Neuropathic
pain is frequently present [2]. Depending on the type of
pain, an appropriate analgesic should be selected [59]:
conventional analgesic and/or antiepileptic drugs (pre-
gabalin, gabapentin), tricyclic antidepressants, or non-
selective serotonin reuptake inhibitors for neuropathic
pain. But to our knowledge, there are no specific studies
on their effectiveness in the management of ulcer pain.
EMLA cream can be applied before detersion or lidocaine
spray, which has an almost immediate but superficial
effect [58]. During the treatment, a nitrogen monoxide-
oxygen mixture (MEOPA®) can be inhaled, which has an
analgesic, sedative, and amnesiac effect allowing a less
traumatic memory of the act. However, it is difficult to
use in outpatient settings [60]. Furthermore, a study
showed that the application of EMLA® cream was more
effective than nitrous oxide during ulcer debridement
[61]. Anxiety can generate muscle contractions, increase
the heart rate, and increase the pain intensity [59]. The
use of benzodiazepines before care is possible, as well as
the use of music and, if the practitioner is trained, hypno-
analgesia, but no specific study seems to exist. Self-
adhesive edges and dressings that adhere should be
avoided [60]. Ibuprofen-based dressings have an anal-
gesic effect, provided that the ulcer is exudative [62]. In
addition, when cleaning with saline, the ulcer should be
dabbed, not rubbed [60]. Finally, several articles reported
the analgesic efficacy of sevoflurane for topical use in
venous or arterial ulcers and pressure sores. This mol-
ecule is used in general anaesthesia. There are no large-
scale studies, just case reports and small prospective
series. Its tolerance is good, with no systemic adverse
effects, and only a few local adverse effects: erythema and
a sensation of heat, burning, or pruritus [63, 64].
Aphthous Stomatitis
Recurrent aphthous stomatitis is a common cause of
pain. Regardless of cause, several symptomatic topical
treatments are possible: corticosteroids, cyclosporine,
retinoids, antimicrobials, anaesthetics [65]. Small lesions
are often adequately controlled with use of a protective
emollient such as Zilactin or orabase, used alone or with a
678 Dermatology 2023;239:675–684
DOI: 10.1159/000531758
topical anaesthetic [66] for instance with lidocaine or
benzocaine [67]. In patients with more frequent or severe
disease, the use of a topical glucocorticoid is an effective
therapy to decrease the size and healing time of the ulcers
[66]. Another approach is the prevention of ulcer for-
mation, especially for major ulcer forms. Colchicine is
effective for this indication [66]. In the most severe cases,
the use of thalidomide remains possible [66]. Dapsone,
azathioprine, and etanercept are also effective to manage
major RAS [66]. Table 1 summarises the general analgesic
recommendations for neuropathic or nociceptive pain-
inducing pathologies.
Pain Management in Dermatologic Procedures
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Skin Surgery
During surgical interventions on the skin under local
anaesthesia, the pain felt by the patients is moderate and
corresponds to the level of anaesthesia infiltration
[68–72]. Post-operative pain is maximal on the same day
[73]. Preoperative anxiety is predictive of greater post-
operative pain and even chronic pain [69, 74–76]. The
first approach is to prepare the patient well for the
surgery, with clear explanations of the procedure and the
expected benefits. For the most anxious patients, pre-
medication with benzodiazepines can be considered [77]
(midazolam has been successfully studied in healthy
patients undergoing Mohs surgery [78]). A dose of an-
algesic before or just after the procedure reduces pain
during the first 24 h (acetaminophen, ibuprofen, diclo-
fenac, celecoxib) [77]. For post-operative pain, ice can be
applied to the surgical site [72, 77], and the patient can
take acetaminophen or NSAIDs as a second-line treat-
ment [79, 80]. Opiates are rarely needed, so it is not
advisable to prescribe them routinely, especially as there
is a risk of misuse and abuse [70]. Concerning the pain
experienced during the injection of anaesthetics, it is
particularly intense in the face, nose, extremities, axillary
hollow, and perineum [70, 73, 75]. The application of a
topical anaesthetic such as lidocaine/prilocaine cream
(EMLA®) before could be effective in reducing the pain
during anaesthetics injection [81], notably in the peri-
neum [71]. However, a randomized control trial about
open trigger digit did not show any statistical difference in
pain between the EMLA and placebo group during the
needle insertion [82], and another trial found that EMLA
cream prior to digital nerve block of the big toe had no
clinical benefit [83]. In all cases, the injection technique
also influences the pain felt and can be modulated. It is
less painful to inject at a 90° angle and to inject slowly [84, 85].
Hayoun/Misery
Table 1. Summary for practical pain management (general rules)
Type of pain Main conditions
Procedural pain Skin surgery
Injections
PDT
Wound care
Skin disease-induced nociceptive pain AD
Psoriasis
Pemphigus
Stevens-Johnson, Lyell
Skin ulcers
Herpes
Aphthous stomatitis
Neuropathic pain Herpes zoster
PHN
Applying cold before infiltration, for example, cold air
[86] or ice [87], or using a mechano-anaesthesia tech-
nique like vibration device [76, 87–89] is effective in
reducing pain. A study shows that nitrogen monoxide-
oxygen mixture (MEOPA) was more effective in re-
ducing anaesthesia-induced pain during Mohs surgery
compared to ice and vibration [90]. The use of lidocaine
buffered with sodium bicarbonate in 3:1 ratio, producing
a less acidic pH, significantly reduces pain. Sodium
bicarbonate is more effective than sodium chloride as a
diluent because it will release CO2 at the injection site
with a direct local anaesthetic effect [85, 91, 92].
Attention distraction techniques can be associated.
Two systematic reviews on the use of musical interven-
tions in surgery found that music reduced pain and
anxiety [93, 94]. The type of music and duration did not
seem to influence the outcome, but a tempo of 60–80
beats per minute, an absence of speech, low tones, strings,
and a maximum volume of 60 dB were the most effective
[93]. In dermatology, the results are contradictory; a
study shows that a classical music intervention signifi-
cantly reduced patient pain and anxiety associated with
local anaesthesia during non-Mohs dermatologic pro-
cedures [95]. But a prospective study about patient un-
dergoing skin surgery showed no significant relief of pain
and anxiety when listening to music. However, the
anxiety of the operator decreased significantly, with
possible benefits for the surgical result [96]. Anxiety may
mediate the relationship between musical interventions
and pain experience. In general, the risk of bias in these
studies was moderate to severe and limits the interpre-
tation of the results, explaining that they are contradic-
tory from one study to another. There is little evidence to
Pain Management
First intention Second intention
Local anaesthesia Premedication
Post-operative analgesics
according to pain intensity
Conversational hypnosis
MEOPA
Treatment of the disease Analgesics according to
pain intensity
Gabapentinoids Analgesics according to
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Antidepressants pain intensity
suggest a benefit of listening music during skin surgery
[97], but its implementation is easy and inexpensive with
a possible beneficial effect and no notable adverse
events [84].
Technologies that modify reality by enhancing or
modifying a real or artificially created computer envi-
ronment could be beneficial to reduce pain and anxiety
during skin surgery [98]. Few studies specifically concern
cutaneous surgery. A prospective study on 100 patients
showed that virtual reality was effective in reducing
anxiety during Mohs surgery but did not significantly
reduce pain [99]. Until now, there has been no codified
use of this technique.
Hypnosis is increasingly used and studied in the
medical field for pain relief [100]. A randomized con-
trolled trial showed no analgesic effect of hypnosis but a
reduction in anxiety during dermatologic surgery [101].
Conversational hypnosis is a possible approach and was
effective in reducing perioperative anxiety in a study in a
gynaecological surgery department. However, the care-
giver must be trained [102]. There are no trials yet in
dermatology with this technique. Conversational anx-
iolysis, on the other hand, is used intuitively by
practitioners [68].
Photodynamic Therapy
Pain during photodynamic therapy (PDT) is the main
limiting adverse effect of the use of this technique [103].
Topical anaesthetics are not effective in reducing pain
[104]. Scalp nerve blocks provide an effective method for
pain management during PDT for patients with extensive
actinic keratoses [105, 106]. Another study showed that
nerve block is superior to cold air [107]. Another controlled
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trial showed that scalp nerve blocks are more effective than
intravenous analgesia (piritramide and metamizole) or cold
air analgesia; and no significant difference in terms of
pain relief was found between cold air alone and cold air
combined with intravenous analgesic [108]. Cooling
methods permit significant reduction in pain, but minor
[109, 110] and there is no difference between cold-water
spray and cool pack [109]. Pause illumination was more
effective [109, 111]. Nitrous oxide/oxygen mixture is a
very effective and well-tolerated method for achieving
significant pain reduction during PDT [112]. Hypnosis
is poorly studied in PDT; in a series of 12 patients
undergoing PDT, hypno-analgesia was effective for 8
[113]. TENS permitted reduction of pain during pro-
cedure for AK on the scalp in a study. The electrodes
were placed on the shoulder [114]. Finally, there is less
discomfort with daylight PDT [115].
Botulinum Toxin and Dermal Filler Injections
The injections for aesthetic purposes in the face are
painful. Several analgesic techniques have been tested,
often on small patient samples. The application of a
system delivering a vibration during the injection seems
to significantly reduce the pain during the injection of
botulinum toxin [116, 117] or dermal filler [118] in the
face. Several cold anaesthetic techniques have been
studied with encouraging results. The application of
fluoroethane- or ethyl chloride-based cooling spray sig-
nificantly reduced pain during botulinum toxin or dermal
filler injections in the face [119]. It also appeared to be
effective in reducing discomfort during palmar and
plantar botulinum toxin injections for hyperhidrosis
[120]. It was compared to ice packs during palmar
neurotoxin injections for hyperhidrosis and was superior
in terms of pain reduction [121]. Similarly, the ethyl
chloride spray was more effective than EMLA cream in
reducing pain during neurotoxin injections in the fore-
head [122]. Another series of patients receiving botuli-
num toxin injections for palmar hyperhidrosis showed
the superiority of ice packs over EMLA cream in reducing
pain [123]. In contrast, Elibol et al. [124] found that both
EMLA cream and ice gel pack significantly reduce pain
when injecting periocular neurotoxin, but there was no
difference between ice and EMLA. Applying a spot
cooling device reduces patient discomfort in patient
undergoing dermal filler procedure [125]. Finally, hyalur-
onic acid filler is now often prepared with lidocaine, which
significantly reduces the sensation of pain immediately after
the procedure [126]. An open-label study found that nitrous
oxide/oxygen mixture significantly decreases VAS pain
score during botulinum toxin injection in the axillae and
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palms [127]. Finally, hypnosis seems to be an effective tool
to reduce pain related to palmar botulinum toxin injections
[128]. General analgesic rules for procedural pain are given
in Table 1.
Conclusion
We propose a practical summary in Table 1. There are
a lot of data emerging on the painful nature of AD and
psoriasis. However, the effectiveness of the treatments for
these diseases is evaluated based on the relief of pruritus
but still little on pain relief, even though additional trials
are carried out in this sense. As for general pain treatments,
the rules of which are laid down by the WHO in the
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context of cancer-related pain, they have not been studied
specifically in skin diseases, except in PHN. With regard to
dermatological procedures, analgesic drug management is
rather well studied in skin surgery. The data are less robust
for PDT or botulinum toxin injections. In addition, there
are new data on non-drug analgesic methods such as
hypnosis, TENS, virtual reality, or musical interventions.
Key Message
Analgesic methods are numerous but still too little studied
specifically in dermatology.
Conflict of Interest Statement
Laurent Misery: Galderma, Lilly, and Pfizer – speaker, inves-
tigator, and consultant, and Pierre Fabre – speaker and consultant.
Mathilde Hayoun: no conflict of interest to declare.
Funding Sources
No funding was received for this study.
Author Contributions
Laurent Misery: conceived and designed the review, critical
review of the intellectual content of the work, final approval of the
version to be published, and agreed to be accountable for all as-
pects of the work in ensuring that questions related to the accuracy
or integrity of any part of the work are appropriately investigated
and resolved. Mathilde Hayoun: corresponding author, conceived
and designed the review, collected the data, wrote the paper, final
approval of the version to be published, and agreed to be ac-
countable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Hayoun/Misery
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