Postoperative pain in dermatological surgery: passwords to manage it

by Verónica Ruiz

POSTOPERATIVE PAIN IN DERMATOLOGICAL SURGERY: PASSWORDS TO MANAGE IT

The pain, according to the International Association for the study of pain (IASP) is defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage.

We see, therefore, that pain is subjective and the IASP highlights that it is associated with tissue damage or that it is described as caused by it, but it does not clearly say that pain is caused by this damage.

The perception of pain is a complex process that implies on the one hand, the sensory information in the same place of the tissue injury, and, on the other, the subsequent propagation of this information to the central nervous system, where the pain centers in the cerebral cortex will be activated and that is when that pain will be perceived.

“The postoperative pain that is usually experienced by patients after dermatological surgery is usually perceived as mild, generally during 2 or 3 days after the first days of the surgery and, in the majority of occasions, can be controlled by common pain relievers such as paracetamol”.

However, there are less frequent situations in which the pain that the patient perceives is unusually severe, and cannot be managed with common analgesics and requires additional medical attention.

Next, we will review important concepts related to those factors than can influence the perception of postoperative pain, instruments available to evaluate this pain and how we can manage it.

 
What are the factors that influence in the perception of postoperative pain?

Currently we have very few data published in the medical literature that attempt to answer this question. The main studies that have investigated in this regard show disparate and heterogeneous results, mainly due to differences in terms of the methodology used and the numbers of patients included.

In a study of 443 patients who underwent Mohs surgery (MMS), they found that the age under 66 years, the use of flaps for the reconstruction of the surgical defect and the fact of having removed several injuries in the same surgical intervention were factors significantly associated with an increase of postoperative pain.

However, in another study with 158 patients, also after MMS, they found no relationship with age or the type of reconstruction used, but with the location on the scalp and, in the same way, with the fact that several tumors were removed in the same surgical procedure.

Anxiety or fear of pain has been shown to be an acute and chronic pain. In this sense, the degree of anxiety experienced by the patient before, during and after the surgery also has been related to the degree and duration of the postoperative pain perceived.

In fact, we found 2 related studies where the authors concluded that those patients who had high anticipatory anxiety pain also had significantly higher postoperative pain.

 
What instruments do we have to assess postoperative pain?

To measure the pain we have scales, which are instruments (also subjective) designed to evaluate, reassess and compare the pain.

Its fundamental application is the assessment of the response to the treatment rather than to the diagnosis of the pain.

The scales can be unidimensional and multidimensional; the first one evaluate the intensity of the pain whereas the second ones also perform a quantitative assessment of pain, that is, how the pain impacts other vital aspects.

The most widely used scales in daily clinical practice are the unidimensional scales, mainly 3:

  • Numeric scale: The use numbers that go from lowest to highest in relation to the intensity of the pain. The most used range from 0 to 10, with 0 being the absence of pain and 10 being the maximum pain.
  • Verbal descriptive scale: The patient expresses the intensity of their pain using a conventional system, the most used descriptions being mild-light, moderate, severe-intense, unbearable.
  • Analog scale (EVA): The most used method due to its greater measurement sensitivity. It doesn’t use numbers nor descriptive words but it requires major collaboration from the patient.  It consists of a line of 10 cm in length where the minimum and maximum pain level is indicated at the end and the patient has to mark with a line the place where they think the intensity of their pain corresponds.
Management of postoperative pain

The appropriate choice of analgesic depends fundamentally on the intensity of the pain and on each patient.

It is important to have in mind your opinion as a patient about the drugs at the time of informing one and prescribing any postoperative analgesia since we can find ourselves with different scenarios.

While there are patients who actively request a specific recommendation on what medications they can use to mitigate the pain, others know well which drugs work best for them and other patients prefer not to take any despite having pain.                                            

When advising on specific analgesia guidelines, it is important to bear in mind the following:

  1. It is recommended to carry out a preventive treatment, that is, to anticipate the pain.
  2. The analgesic ladder of the OMS is a good tool for the gradual use of drugs, however, this strategy may not be adequate in certain situations because it would delay the pain control. That is why currently and in certain contexts, it is proposed to directly use the appropriate analgesic according to the intensity of the pain without the need for escalation.
  3. NSAIDS, like Ibuprofen and Diclofenac, present renal and hematological toxicity, increasing the risk of bleeding, which is why they would not be the most recommended drugs as the first analgesic step after the surgery.
  4. The opiates are the most powerful analgesics, however they present important adverse effects such as nausea and vomiting, drowsiness and respiratory depression. That is why it could be more reasonable to use them in intense pain that cannot be controlled with common analgesics. It is curious to note that in USA, up to 7% of the patients undergoing CMM receive opiates for postoperative pain, despite the fact that the vast majority of patients perceive mild pain after this procedure.

In my experience, the analgesic that I usually prescribe most frequently for the control of postoperative pain is paracetamol 1g every 8-12 hours, starting the doses the same day of the surgery, being able to alternate with metamizole if necessary.

With this guideline, in the majority of occasions, we are able to control the pain after dermatological surgery.

 

Conclusion:

The pain that patients experiment after the dermatological surgery is usually a mild one and generally is controlled by common pain relievers.

Between the factors that have been associated with this postoperative pain exists the presence of anticipatory anxiety or the fear of the patients own pain and the factor of having removed more than one tumor injury.

Paracetamol can be used to manage this pain, reserving other drugs such as metamizole, opiates and NSAIDs for specific situations that require it.

 

REFERENCES

  • Firoz BF, Goldberg LH, Arnon O, Mamelak AJ. An analysis of pain and analgesia after Mohs micrographic surgery. J Am Acad Dermatol 2010; 63:79–86.
  • Limthongkul B, Samif F, Humphreys TR. Assessment of postoperative pain after Mohs micrographic surgery. Dermatol Surg 2013;39:857–63.
  • Affleck AG. Predicting pain during and after Mohs micrographic surgery: the need to consider psychological factors. J Am Acad Dermatol 2011;64:788.
  • Andrea F Chen, David C Landy, Erik Kumetz, Gerard Smith, Eduardo Weiss, Eli R Saleeby. Prediction of postoperative pain after Mohs micrographic surgery with 2 validated pain anxiety scales. Dermatol Surg 2015 Jan;41(1):40-7.