Needle phobia is typically a childhood affliction that decreases with age (Orenius et al, 2018). However, it can affect 1 in 10 adults (Szmuk et al, 2014), causing patients to avoid routine check-ups and appointments, often to the detriment of their health (McMurtry et al, 2015). Some 75% of needle-phobic patients experience a vasovagal reflex provoked by the stimulus of a needle (Jenkins, 2014), characterised by a slow heart rate and sudden drop in blood pressure, triggering fainting or loss of consciousness (Alboni and Alboni, 2014).
Causes
According to Hamilton (1995), 80% of patients with needle phobia described the same strong needle fear in a first-degree relative, indicating that it is learned from a role model during childhood (Du et al, 2008). The fear of needles tends to start between 5 and 10 years of age, and can be made worse by a negative or anxious reaction from a parent during a routine vaccination (McMurtry et al, 2015).
In cases of associative fear, the patient may connect all needle procedures with a particularly traumatic medical situation that they, or someone they love, experienced (Du et al, 2008). A prior instance of being held down or restrained during a vaccine or blood test can result in resistive needle phobia in children and adolescents, which is more active and combative (Orenius et al, 2018). Patients with associative fear are less likely to have the vasovagal response (Jenkins, 2014). There is also a compelling theory that needle phobia is a part of human evolution, whereby people faint or ‘play dead’ as a base evolutionary reaction to sharp objects that pierce the flesh (Orenius et al, 2018).
Follow-ups
In aesthetic practice, Weiss and Lavin (2009) discovered that an experience of pain can make patients reluctant to book a follow-up appointment for botulinum toxin treatment; however, pain is not the only concern for needle-phobic patients, and practitioners are required to take their time to ascertain the best course of action for such a patient who has requested cosmetic treatment.
New technology
More promisingly, recent technologies allow us to provide needle-free treatments as alternatives to those that were traditionally administered by needle. This technology helps to bypass the extreme physical reaction from phobic patients, opening up aesthetic treatments to not only the needle phobic, but also patients sensitive to pain and bleeding.
Cognitive behavioural therapy
Patients with needle phobia can consult mental health specialists for exposure-based cognitive behavioural therapy (CBT) to avoid fainting in practice (Chapman and DeLapp, 2014). Unfortunately, this approach is not an immediate solution suitable for a patient already in the treatment room—it takes time and commitment from the patient. This approach is best for patients without the vasovagal reflex (Jenkins, 2014). While the use of virtual reality technology is a distraction technique revolutionising vaccinations for children (Chad et al, 2018), the headset is impractical for many aesthetic procedures.
A topical anaesthetic is a useful option to offer patients, as a study by Weiss and Lavin (2009) discovered that 19% of naive patients and 31% of experienced patients put off booking a follow-up appointment for cosmetic botulinum toxin treatment due to reluctance to experience pain at the injection site. However, the use of such topical anaesthetics may only work on patients apprehensive about pain—a patient with needle phobia is likely to be scared of the needle and the perceived potential for bleeding, even if the procedure does not hurt.
Needle-free injection technology
Fortunately, a new form of technology has been developed specifically to help patients who struggle with needle phobia. Hand-held devices using needle-free injection technology (NFIT) work by propelling the drug or treatment through the skin using gas pressure, shockwaves or electromagnetic force (Ravi et al, 2015). The advantage of using such a needle-free, highly targeted delivery system is that it can help to alleviate the needle-phobic patient's fears (Szmuk et al, 2014). However, the amount of pain patients experience through this method is difficult to quantify, as some studies indicate no pain, whereas others indicate mild pain, or even that the pain is comparable to that of a standard needle injection (Nantel-Battista et al, 2013). Further research is required to fully understand this effect.
As the technology becomes more popular, many aesthetic-based models are being developed, including specific delivery systems for mesotherapy. There are also models such as Med-Jet (Salient Medical Solutions), which can be used for mesotherapy, as well as botulinum toxin treatments, dermal fillers and platelet-rich plasma (PRP) treatment. Nantel-Battista et al (2013) noted that not all jet injector devices are equal, particularly in the treatment of plantar hyperhidrosis with botulinum toxin, so it is important to research and understand the limitations of each device before using it to treat a patient with needle phobia. Furthermore, it should be kept in mind that the depth and shape of skin penetration depend on the amount of pressure applied (Seok et al, 2016).
Is it really a needle phobia?
According to Szmuk et al (2014), needle phobia affects at least 10% of the general population. It is classified in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as a type of blood-injection-injury phobia (Jenkins, 2014). Patients with true needle phobia often have a physical reaction to the sight or feel of a needle, or to the prospect of one being used on them, involving a vasovagal reflex, which includes feeling faint, vertigo, light-headedness, nausea, sweating or pallor (Hamilton, 1995). However, 25% of needle-phobic patients do not have the vasovagal response (Jenkins, 2014).
Needle phobia can have serious consequences, as many patients will avoid the possibility of a blood test or injection—mainly by avoiding preventative medical care (McMurtry et al, 2015). While aesthetic procedures are by and large elective, needle phobia can be a major barrier to treatment.
The risk for the patient
According to Hamilton (1995), needle-phobic patients who agree to needle procedures can experience dizzy spells and fainting brought on by low blood pressure, along with sudden falls, convulsions and loss of bladder or bowel control. At best, each of these effects can be extremely distressing and embarrassing to the patient, compounded by the disappointment at not being able to go ahead with the chosen aesthetic treatment. At worst, the patient may be injured by their fall, or, in extremely rare cases, if the patient has atherosclerosis, it can be fatal (Hamilton, 1995). Hamilton (1995) also noted that, while the period of unconsciousness may vary from 10 minutes to 2 hours in rare cases, many patients report a feeling of anxiety, weakness and malaise that can last for days after the vasovagal event. If the patient has an associative needle phobia, they are more likely to display distress and anxiety.
Aesthetic practitioners
In an aesthetic setting, it is imperative that the practitioner always considers the wellbeing of their patient over the importance of the procedure. Offering non-invasive techniques can help (Szmuk et al, 2014), as can good communication between patient and practitioner.
However, given the risks outlined above, it is important that practitioners consider needle-phobic patients on a case-by-case basis, ensuring that they reserve enough clinic time to talk these patients through the procedure and answer any questions, which may help to allay some of the patient's fears. The best practice would be to recommend CBT for patients who are not yet ready to undergo cosmetic treatments involving needles. These strategies are as much for the practitioner as for the patient. With careful planning, and the patient's commitment to CBT, it is possible to improve the patient's quality of life and provide them with the aesthetic results they want.
Mass media influence
Although needle phobias usually stem from an automatic vasovagal reaction or as an associative fear (Jenkins, 2014), it can be argued that fear of needles is heightened in the public by depictions of needles in medical and body horror films, as well as news stories about people with needle phobias, which are often accompanied by close-up photographs of syringes and blood. While needle phobia is a real condition requiring treatment, the general public need to be educated on the difference between a phobia and a simple dislike—after all, few people want to experience pain, even if the procedure benefits their appearance (Weiss and Lavin, 2009).
Conclusion
Needle phobia is a type of phobia that can result in a serious vasovagal reaction or panic in the case of associative fear. Patients with needle phobia are less likely to seek out routine medical treatment, and the fear may be a barrier to them accessing aesthetic treatments. Aesthetic practitioners need to measure up the risks associated with needle phobia before agreeing to treat needle-phobic patients, and they should direct patients to seek CBT treatment where necessary. NFIT is a viable alternative to syringe needles for a variety of aesthetic treatments.