Local Anesthetic Injection Site Pain Does Not Increase Across Mohs Stages

Patients can be reassured that Mohs procedures are usually associated with only mild to moderate levels of intraoperative pain.

Mohs stage is not associated with increased anesthetic injection site pain during Mohs micrographic surgery (MMS), according to study results published in Journal of the American Academy of Dermatology.

Researchers conducted a multicenter longitudinal cohort study of patients who presented to the Department of Dermatology at either Northwestern University or Loyola University for MMS. Only participants whose tumors required multiple MMS stages were included in the study. Demographic data were collected at intake. The primary outcome was pain level associated with each MMS stage, rated by participants using the 10-point visual analogue scale (VAS). Participants were asked to rate pain level immediately after each anesthetic injection and prior to removal of a Mohs stage.

A total of 295 participants (mean age, 64.2 years; 58.0% White men) were enrolled for a total of 841 recorded Mohs stages. Of these stages, 330 were excluded because complete anesthesia response was reported from the prior injection and thus did not require subsequent injection. The most frequent surgical locations were the cheek and eyelid. The average wait between Mohs stages was 63.8 minutes. Data were collected for up to 7 stages, though only 4 patients required more than 5 stages.

Mean pain ratings were not significantly different between subsequent stages of Mohs surgery (stage 1, 2.5; stage 2, 2.5; stage 3, 2.7; stage 4, 2.8; stage 5, 3.2; P =.770). Overall, 37.2% of participants reported moderate pain during stage 1. This proportion did not increase significantly in subsequent stages (all P >.05). A total of 9.9% of participants reported severe pain in stage 1. Among those who required 5 stages, the incidence of severe pain increased nominally to 12.5% at stage 5 (P =.05).

This study extends earlier work showing that MMS is a safe, effective, and generally well-tolerated procedure.

Overall, the patient-reported pain level associated with anesthetic injection did not significantly increase with subsequent Mohs stages. Mean VAS scores and the rates of moderate and severe pain did not change across stages.

Limitations of the study include the fact that the study was conducted at just 2 academic sites in an urban environment, which may limit the generalizability of the results.

“This study extends earlier work showing that MMS is a safe, effective, and generally well-tolerated procedure,” the researchers conclude. “Future research may investigate other means whereby awake Mohs patients can be kept comfortable during surgery.”

This article originally appeared on Dermatology Advisor


Dirr MA, Christensen RE, Anvery N, et al. Pain of local anesthetic injection of lidocaine during subsequent stages of Mohs micrographic surgery: a multicenter prospective cohort study. J Am Acad Dermatol. Published online March 9, 2023. doi: 10.1016/j.jaad.2023.02.049