Peter Lio, MD, FAAD: Minimizing Pain and Addressing Systemic Malignancy With Alternative Therapies

At the 2024 American Academy of Dermatology Annual Meeting in San Diego, California, Peter Lio, MD, FAAD, presented sessions on the topics of addressing systemic malignancies with alternative or adjunctive therapies and the importance of minimizing pain in dermatology procedures.

Lio, a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine and the Founding Director of the Chicago Integrative Eczema Center, spoke with Dermatology Times to discuss highlights and pearls from his sessions, "Skin and Systemic Malignancy" and "Pain-free Dermatology: Minimizing Discomfort in Procedures for Children and Adults."

Transcript

Peter Lio, MD, FAAD: Hi, I'm Peter Lio. I'm a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine and the Founding Director of the Chicago Integrative Eczema Center here in Chicago, Illinois.

Another wonderful session was about the role of the skin and sort of the the aspects of skin in malignancy, and it's a very broad topic, because we know that there are many chemotherapy-induced skin problems, we know that there are some paraneoplastic syndromes that present on the skin. The piece that I talked about really was on alternative and complementary approaches, and how can they play a role?

One of the things I do first is I talk about things that should not be part of this plan. For example, we talk about black salve, we talk about this idea that using things topically to try to, for example, treat melanoma, is generally not a standard of care and actually can cause all sorts of trouble, and we talked about some of the case reports and the literature that says this can be extremely dangerous. So we want to get that out of the way.

Then we talked about some of the big issues that affect our patients with malignancy, and the biggest piece for me, at least that I'm called to consult for, is itch. So it ends up being a little bit of a session for me about: How do we approach it in some holistic ways? Because we know many patients have had everything but the kitchen sink thrown at them, and they're still really itchy, and it's an interesting place for alternative and complementary treatments. Some of the things we talked about are acupuncture and acupressure. We talked about some herbs that may actually be helpful. Some supplements like quercetin, which may play a role especially if it's histaminergic mediated. So, there are some things that we can do and even some relaxation techniques and distraction techniques and cognitive behavioral therapy; all these things can play a bit of a role for patients that are suffering.

Again, they're not going to necessarily solve the whole thing, and they certainly are not going to obviate conventional medicines. But for the patient who's still uncomfortable, and you're saying, "Gosh, I don't know what else to do." These can be really nice adjunctive therapies that are generally very gentle, well tolerated, especially in somebody who's sick. In polypharmacy that you say, "Hey, you know what? We've actually improved their quality of life; we've helped them out." Oftentimes, the patients are incredibly grateful that we haven't just given up and said, "Well, we tried the 6 medicines that are in the book. Bye." That's not humanistic. That's not taking good care of the individual. So we need to sometimes do more, and sometimes just that tender love and care, that commitment to trying things, is enough to help the patient get over that hump and say, "You know what? I'm feeling a bit better about all this, and I appreciate your care." I've had patients say that all the things I do do not always work. I don't hit a homerun every time. I don't always even get on base every time. A lot of times, you try stuff and it doesn't work. But I think if the patient senses you're really invested in getting them better, and you're willing to think out of the box, that goes a very long way.

For several years now, I've been lucky enough to direct a course on pain-free dermatology, and the idea is that it's really thinking about kids. But that's not all: Who can benefit from this? Adults can benefit just as well. In fact, in my own practice, I'm about 50/50, kids and adults. I use these techniques everywhere.

One of the most important take home messages is that to give somebody a more comfortable procedure, it's not just to make them feel better. That's great. That's a huge win. But actually, there's a selfish goal in there, too. It turns out procedures are more successful when the patient is more comfortable, so it actually helps everybody; everybody wins.

We talked about a bunch of different things in that sessions. In that session, we talked about, first of all, some basic pharmacologic things to help with the pain, so things like topical anesthetic and how to maximize that, things like using cooling and vibration to again, dampen the nerve sensation. We talk about distraction techniques, because it turns out that attention, if the patient is paying attention to the procedure, it's much, much more intense. So we can use distraction methods. It can be as simple as talk therapy, making them tell us about something, moving their mind away. It can be as sophisticated as using something like an iPad, or even a virtual reality- type headset, where they're completely immersed in another world; their attention is far, far away.

It turns out that that engagement, if they're engaged in something, they're watching a film or a show, that's helpful, for sure. But if they're actually doing something and thinking about stuff, they tend to be incredbiyl easy to take care of in that scenario, especially kids. They're sort of in a state that's like hypnosis, frankly. What's great is there have been some studies showing that that kind of engagement is on par, or even better than, pharmacologic sedation and things like that. So it's really neat to be able to see how powerful these adjunctive tools can be, and then I think the final piece is really making an environment that allows for all these things to come together: the best, sort of most gentle, pharmacologic treatments, the good techniques, warming up our solutions, if we're going to inject things, going slowly. Then of course, using these distraction techniques to help all these aspects of the procedure to go great and have patients walking out of that office saying, "That was a piece of cake. This practitioner was amazing." That's really our goal.

[Transcript has been edited for clarity.]