Theoretical description of a local anesthesia protocol with non-pharmacological strategies for dermatological procedures in children

Funding: None
Conflict of interest: None
Submitted on: 05/28/2025
Final decision: 09/11/2025
How to cite this article: Brufatto JPT, Maciel MG, Martinelli ASS, Barbosa GS, Kucarz TJ, Pires Júnior LRDB, Magalhães RF, França AFEC, Buffo TH, Secamilli EN. Theoretical description of a local anesthesia protocol with non-pharmacological strategies for dermatological procedures in children. Surg Cosmet Dermatol. 2025; 17:e20250478.

Abstract

Pain and anxiety management during pediatric dermatological procedures is a crucial aspect of medical care. Skin biopsies can cause stress and discomfort in children, negatively impacting the relationship between health care providers, patients, and caregivers. This study describes a local anesthesia protocol based on non-pharmacological techniques, consisting of prior explanation, parental support, visual distraction, and the use of cold or vibration before pharmacological anesthesia. Implementing this protocol may reduce pain and anxiety perception while offering a low-cost, low-tech, and safe care option.

Keywords: Dermatology; Pediatric Anesthesia; Biopsy; Pain

INTRODUCTION

Pain and anxiety are fundamental aspects of the medical experience in the pediatric population, directly impacting treatment adherence, longitudinality of care, and the quality of care provided.¹ Attention to these factors is critical to ensure a safer and more humanized environment,¹ especially in invasive procedures such as skin biopsies.²

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential physical harm.³ This perception of pain may be intensified by psychosocial factors such as anxiety, fear of the unknown, and a sense of vulnerability.⁴ Dermatological procedures, such as skin biopsies, often trigger an uncontrolled anxiety response, making it essential to adopt effective strategies to reduce suffering for both children and their caregivers during medical procedures.^5,6

Child mental health is a relevant factor to be considered, as it may compromise how the procedure is experienced and negatively influence longitudinality of care within the health system.^7,8 Children who undergo painful procedures without adequate emotional support may develop fears and trauma related to medical visits, impairing adherence to necessary treatments.^7,8 In addition, poorly managed pain may result in neurophysiological changes over time, increasing sensitivity to pain in future events and affecting the child’s perception of health care.^7,8 Therefore, strategies that aim at minimizing pain and anxiety are critical to promoting more humanized care and improving the child’s experience of caring for their own health.⁹

A multidisciplinary approach to pediatric pain management is a frequent subject in the literature, combining play-based interventions and nonpharmacological techniques.^5,6,9 However, the development of structured protocols remains uncommon in the scientific literature. The development of guidelines for pediatric dermatological procedures may represent an important contribution to improved clinical and emotional outcomes in children undergoing invasive procedures such as skin biopsies, and may also foster further research in this field.

Several studies indicate that the combination of local anesthesia with nonpharmacological methods, together with distraction techniques and emotional support, can significantly reduce pain and discomfort in children undergoing invasive procedures. The present study aimed to describe a local anesthesia protocol based on nonpharmacological therapies, using sensory distraction strategies and emotional support for skin biopsy procedures in children. The goal is to reduce pain perception, minimize anxiety, and improve cooperation among pediatric patients, thereby providing a more humanized experience.

METHODS

A narrative literature review was conducted using the PubMed, Scopus, and SciELO databases. Articles published within the last 5 years were selected using the following English descriptors (MeSH terms): “pediatric OR children OR child OR neonatal,” “pain management,” and “non-pharmacology anesthesia.” Inclusion criteria comprised clinical studies, systematic reviews, and meta-analyses addressing strategies for the management of pain and anxiety in children undergoing surgical procedures. Studies involving exclusively adult samples or addressing only pharmacological anesthesia without integration of non-pharmacological strategies were excluded. Figure 1 summarizes the results of the literature search.

Based on the data collected, a structured protocol for local anesthesia in children undergoing skin biopsies was developed, incorporating psychological and sensory approaches.

RESULTS

The protocol comprises four stages. The first stage consists of providing clear, age-appropriate explanations about the procedure, addressing both the child and their caregivers.^9,10,11 The guidance should be presented in a playful and accessible manner, using resources such as stories, dolls, drawings, or illustrated books, with the aim of demystifying the experience and reducing procedure-related anxiety. ^9,10,11 The second stage involves encouraging parental support, allowing the caregiver to remain by the child’s side during the procedure and promoting physical and verbal contact as a strategy to enhance the sense of emotional security.^12,13 The third stage involves the use of visual and auditory distraction strategies, such as electronic devices to watch videos or listen to stories, helping to shift their focus away from the procedure and consequently reduce stress.^9,14,15 Finally, the fourth stage refers to the application of sensory modulation measures, including prior use of ice or vibratory devices at the biopsy site, with the goal of minimizing the perception of pain associated with infiltration of the local anesthetic.^16,17

The protocol is summarized in Figure 2. Figure 3 illustrates the tools used in our hospital for the application of ice in (A) and vibration in (B).

DISCUSSION

The implementation of play-based strategies has been widely studied and recommended for pediatric patients in intensive care and oncology settings as effective methods to alleviate childhood anxiety and improve treatment adherence.^18,19,20 The use of these strategies allows children greater control over their experience, promotes an understanding of pain beyond its exclusively physical dimension, reduces fear, and provides a more welcoming environment.¹⁹

Emotional support, including verbal encouragement and physical contact from parents, is essential for helping children feel safe.²¹ Studies show that parental presence and physical contact can lower cortisol levels, thereby decreasing the physiological stress response.²¹ In addition, prior preparation and clear, age-appropriate explanations of the procedure to both parents and patients can help reduce uncertainty about procedures, promoting a calmer experience for children.^22,13

Many health care centers worldwide face challenges in performing procedures under general anesthesia in children due to the lack of anesthetic infrastructure, intravenous sedatives, or trained specialists.²³ This limitation can represent a major obstacle to the investigation of serious dermatological conditions, such as genodermatoses or autoimmune diseases, which require histopathological examination for accurate diagnosis.^24,25 The protocol described in this study offers a simple, accessible, and low-cost solution to facilitate dermatological diagnoses, enabling centers without high-complexity hospital infrastructure to advance the evaluation of complex cases.

In addition, the approach proposed in this study may contribute to improved family adherence to treatment, as a properly conducted procedure can strengthen the bond with the health care team and lower the resistance from both the child and their caregivers to medical care.^13,25 This has a direct impact on the longitudinality of care, promoting more comprehensive clinical follow-up and potentially reducing the need for unnecessary interventions in the future.^1,9

The combination of non-pharmacological techniques in pediatric pain management may also help build a more positive relationship between children and health care professionals.²⁰ Children who experience a careful and humanized approach tend to develop greater trust in the medical team, which facilitates long-term care and promotes a more holistic approach to the health of patients and their caregivers across primary, secondary, and tertiary health care settings.^27,28,29,30

CONCLUSION

The combination of local ice or vibration with distraction strategies and emotional support is an effective alternative for minimizing pain and anxiety in children undergoing skin biopsies. The protocol proposed in this study can be implemented in general dermatology services, offering an evidence-based approach to pediatric pain management. Future studies are needed to evaluate its effectiveness using objective measures of pediatric pain and comfort, as well as parameters such as duration and body surface area of ice application, thereby contributing to advances in pediatric dermatological care.

AUTHOR’S CONTRIBUTION:

João Paulo Turri Brufatto
ORCID: 0000-0001-9752-377X
Statistical analysis, Approval of the final version of the manuscript, Conception and design of the study, Preparation and writing of the manuscript, Acquisition, analysis and interpretation of data, Effective participation in the conduct of the study, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.
Marina Gagheggi Maciel
ORCID: 0000-0001-6077-4209
Approval of the final version of the manuscript, Conception and design of the study, Preparation and writing of the manuscript, Effective participation in the conduct of the study.
Adriana Salath Schikiera Martinelli
ORCID: 0000-0001-6723-9188
Approval of the final version of the manuscript, Conception and design of the study, Critical revision of the manuscript.
Giovanna Silva Barbosa
ORCID: 0000-0001-7217-2862
Critical review of the literature, Critical revision of the manuscript.
Thiago Jesse Kucarz
ORCID: 0009-0000-7339-3026
Critical review of the literature.
Luiz Roberto Dal Bem Pires Júnior
ORCID: 0009-0001-6728-420X
Preparation and writing of the manuscript, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied.
Renata Ferreira Magalhães
ORCID: 0000-0001-9170-932X
Approval of the final version of the manuscript, Conception and design of the study.
Andréa Fernandes Eloy da Costa França
ORCID: 0000-0003-1657-4570
Approval of the final version of the manuscript, Conception and design of the study.
Thais Helena Buffo
ORCID: 0000-0002-6833-7596
Statistical analysis, Approval of the final version of the manuscript, Conception and design of the study.
Elisa Nunes Secamilli
ORCID: 0000-0001-9036-4200
Statistical analysis, Approval of the final version of the manuscript, Conception and design of the study, Preparation and writing of the manuscript, Acquisition, analysis and interpretation of data, Effective participation in the conduct of the study, Intellectual participation in the propaedeutic and/or therapeutic approach to the cases studied, Critical review of the literature, Critical revision of the manuscript.

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