Naeha Pathak, BS

To the Editor:

Residency applicants, especially in competitive specialties such as dermatology, face major financial barriers due to the high costs of applications, interviews, and away rotations.¹ While several studies have examined application costs of other specialties, few have analyzed expenses associated with dermatology applications.^1,2 There are no data examining costs following the start of the COVID-19 pandemic in 2020; thus, our study evaluated dermatology application cost trends from 2021 to 2024 and compared them to other specialties to identify strategies to reduce the financial burden on applicants.

Self-reported total application costs, application fees, interview expenses, and away rotation costs from 2021 to 2024 were collected from the Texas Seeking Transparency in Application to Residency (STAR) database powered by the UT Southwestern Medical Center (Dallas, Texas).³ The mean total application expenses per year were compared among specialties, and an analysis of variance was used to determine if the differences were statistically significant.

The number of applicants who recorded information in the Texas STAR database was 110 in 2021, 163 in 2022, 136 in 2023, and 129 in 2024.³ The total dermatology application expenses increased from $2805 in 2021 to $6231 in 2024; interview costs increased from $404 in 2021 to $911 in 2024; and away rotation costs increased from $850 in 2021 to $3812 in 2024 (all P<.05)(Table). There was no significant change in application fees during the study period ($2176 in 2021 to $2125 in 2024 [P=.58]). Dermatology had the fourth highest average total cost over the study period compared to all other specialties, increasing from $2250 in 2021 to $5250 in 2024, following orthopedic surgery ($2250 in 2021 to $6750 in 2024), plastic surgery ($2250 in 2021 to $9750 in 2024), and neurosurgery ($1750 in 2021 to $11,250 in 2024).

Our study found that dermatology residency application costs have increased significantly from 2021 to 2024, primarily driven by rising interview and away rotation expenses (both P<.05). This trend places dermatology among the most expensive fields to apply to for residency. A cross-sectional survey of dermatology residency program directors identified away rotations as one of the top 5 selection criteria, underscoring their importance in the matching process.⁴ In addition, a cross-sectional analysis of 345 dermatology residents found that 26.2% matched at institutions where they had mentors, including those they connected with through away rotations.^5,6 Overall, the high cost of away rotations partially may reflect the competitive nature of the specialty, as building connections at programs may enhance the chances of matching. These costs also can vary based on geography, as rotating in high-cost urban centers can be more expensive than in rural areas; however, rural rotations may be less common due to limited program availability and applicant preferences. For example, nearly 50% of 2024 Electronic Residency Application Service applicants indicated a preference for urban settings, while fewer than 5% selected rural settings.⁷ Additionally, the high costs associated with applying to residency programs and completing away rotations can disproportionately impact students from rural backgrounds and underrepresented minorities, who may have fewer financial resources.

In our study, the lower application-related expenses in 2021 (during the pandemic) compared to those of 2024 (postpandemic) likely stem from the Association of American Medical Colleges’ recommendation to conduct virtual interviews during the pandemic.⁸ In 2024, some dermatology programs returned to in-person interviews, with some applicants consequently incurring higher costs related to travel, lodging, and other associated expenses.⁸ A cost-analysis study of 4153 dermatology applicants from 2016 to 2021 found that the average application costs were $1759 per applicant during the pandemic, when virtual interviews replaced in-person ones, whereas costs were $8476 per applicant during periods with in-person interviews and no COVID-19 restrictions.² However, we did not observe a significant change in application fees over our study period, likely because the pandemic did not affect application numbers. A cross-sectional analysis of dermatology applicants during the pandemic similarly reported reductions in application-related expenses during the period when interviews were conducted virtually,⁹ supporting the trend observed in our study. Overall, our findings taken together with other studies highlight the pandemic’s role in reducing expenses and underscore the potential for exploring additional cost-saving measures.

Implementing strategies to reduce these financial burdens—including virtual interviews, increasing student funding for away rotations, and limiting the number of applications individual students can submit—could help alleviate socioeconomic disparities. The new signaling system for residency programs aims to reduce the number of applications submitted, as applicants typically receive interviews only from the limited number of programs they signal, reducing overall application costs. However, our data from the Texas STAR database suggest that application numbers remained relatively stable from 2021 to 2024, indicating that, despite signaling, many applicants still may apply broadly in hopes of improving their chances in an increasingly competitive field. Although a definitive solution to reducing the financial burden on dermatology applicants remains elusive, these strategies can raise awareness and encourage important dialogues.

Limitations of our study include the voluntary nature of the Texas STAR survey, leading to potential voluntary response bias, as well as the small sample size. Students who choose to submit cost data may differ systematically from those who do not; for example, students who match may be more likely to report their outcomes, while those who do not match may be less likely to participate, potentially introducing selection bias. In addition, general awareness of the Texas STAR survey may vary across institutions and among students, further limiting the number of students who participate. Additionally, 2021 was the only presignaling year included, making it difficult to assess longer-term trends. Despite these limitations, the Texas STAR database remains a valuable resource for analyzing general residency application expenses and trends, as it offers comprehensive data from more than 100 medical schools and includes many variables.³

In conclusion, our study found that total dermatology residency application costs have increased significantly from 2021 to 2024 (all P<.05), making dermatology among the most expensive specialties for applying. This study sets the foundation for future survey-based research for applicants and program directors on strategies to alleviate financial burdens.

To the Editor:

Residency applicants, especially in competitive specialties such as dermatology, face major financial barriers due to the high costs of applications, interviews, and away rotations.¹ While several studies have examined application costs of other specialties, few have analyzed expenses associated with dermatology applications.^1,2 There are no data examining costs following the start of the COVID-19 pandemic in 2020; thus, our study evaluated dermatology application cost trends from 2021 to 2024 and compared them to other specialties to identify strategies to reduce the financial burden on applicants.

Self-reported total application costs, application fees, interview expenses, and away rotation costs from 2021 to 2024 were collected from the Texas Seeking Transparency in Application to Residency (STAR) database powered by the UT Southwestern Medical Center (Dallas, Texas).³ The mean total application expenses per year were compared among specialties, and an analysis of variance was used to determine if the differences were statistically significant.

The number of applicants who recorded information in the Texas STAR database was 110 in 2021, 163 in 2022, 136 in 2023, and 129 in 2024.³ The total dermatology application expenses increased from $2805 in 2021 to $6231 in 2024; interview costs increased from $404 in 2021 to $911 in 2024; and away rotation costs increased from $850 in 2021 to $3812 in 2024 (all P<.05)(Table). There was no significant change in application fees during the study period ($2176 in 2021 to $2125 in 2024 [P=.58]). Dermatology had the fourth highest average total cost over the study period compared to all other specialties, increasing from $2250 in 2021 to $5250 in 2024, following orthopedic surgery ($2250 in 2021 to $6750 in 2024), plastic surgery ($2250 in 2021 to $9750 in 2024), and neurosurgery ($1750 in 2021 to $11,250 in 2024).

Our study found that dermatology residency application costs have increased significantly from 2021 to 2024, primarily driven by rising interview and away rotation expenses (both P<.05). This trend places dermatology among the most expensive fields to apply to for residency. A cross-sectional survey of dermatology residency program directors identified away rotations as one of the top 5 selection criteria, underscoring their importance in the matching process.⁴ In addition, a cross-sectional analysis of 345 dermatology residents found that 26.2% matched at institutions where they had mentors, including those they connected with through away rotations.^5,6 Overall, the high cost of away rotations partially may reflect the competitive nature of the specialty, as building connections at programs may enhance the chances of matching. These costs also can vary based on geography, as rotating in high-cost urban centers can be more expensive than in rural areas; however, rural rotations may be less common due to limited program availability and applicant preferences. For example, nearly 50% of 2024 Electronic Residency Application Service applicants indicated a preference for urban settings, while fewer than 5% selected rural settings.⁷ Additionally, the high costs associated with applying to residency programs and completing away rotations can disproportionately impact students from rural backgrounds and underrepresented minorities, who may have fewer financial resources.

In our study, the lower application-related expenses in 2021 (during the pandemic) compared to those of 2024 (postpandemic) likely stem from the Association of American Medical Colleges’ recommendation to conduct virtual interviews during the pandemic.⁸ In 2024, some dermatology programs returned to in-person interviews, with some applicants consequently incurring higher costs related to travel, lodging, and other associated expenses.⁸ A cost-analysis study of 4153 dermatology applicants from 2016 to 2021 found that the average application costs were $1759 per applicant during the pandemic, when virtual interviews replaced in-person ones, whereas costs were $8476 per applicant during periods with in-person interviews and no COVID-19 restrictions.² However, we did not observe a significant change in application fees over our study period, likely because the pandemic did not affect application numbers. A cross-sectional analysis of dermatology applicants during the pandemic similarly reported reductions in application-related expenses during the period when interviews were conducted virtually,⁹ supporting the trend observed in our study. Overall, our findings taken together with other studies highlight the pandemic’s role in reducing expenses and underscore the potential for exploring additional cost-saving measures.

Implementing strategies to reduce these financial burdens—including virtual interviews, increasing student funding for away rotations, and limiting the number of applications individual students can submit—could help alleviate socioeconomic disparities. The new signaling system for residency programs aims to reduce the number of applications submitted, as applicants typically receive interviews only from the limited number of programs they signal, reducing overall application costs. However, our data from the Texas STAR database suggest that application numbers remained relatively stable from 2021 to 2024, indicating that, despite signaling, many applicants still may apply broadly in hopes of improving their chances in an increasingly competitive field. Although a definitive solution to reducing the financial burden on dermatology applicants remains elusive, these strategies can raise awareness and encourage important dialogues.

Limitations of our study include the voluntary nature of the Texas STAR survey, leading to potential voluntary response bias, as well as the small sample size. Students who choose to submit cost data may differ systematically from those who do not; for example, students who match may be more likely to report their outcomes, while those who do not match may be less likely to participate, potentially introducing selection bias. In addition, general awareness of the Texas STAR survey may vary across institutions and among students, further limiting the number of students who participate. Additionally, 2021 was the only presignaling year included, making it difficult to assess longer-term trends. Despite these limitations, the Texas STAR database remains a valuable resource for analyzing general residency application expenses and trends, as it offers comprehensive data from more than 100 medical schools and includes many variables.³

In conclusion, our study found that total dermatology residency application costs have increased significantly from 2021 to 2024 (all P<.05), making dermatology among the most expensive specialties for applying. This study sets the foundation for future survey-based research for applicants and program directors on strategies to alleviate financial burdens.

To the Editor:

Residency applicants, especially in competitive specialties such as dermatology, face major financial barriers due to the high costs of applications, interviews, and away rotations.¹ While several studies have examined application costs of other specialties, few have analyzed expenses associated with dermatology applications.^1,2 There are no data examining costs following the start of the COVID-19 pandemic in 2020; thus, our study evaluated dermatology application cost trends from 2021 to 2024 and compared them to other specialties to identify strategies to reduce the financial burden on applicants.

Self-reported total application costs, application fees, interview expenses, and away rotation costs from 2021 to 2024 were collected from the Texas Seeking Transparency in Application to Residency (STAR) database powered by the UT Southwestern Medical Center (Dallas, Texas).³ The mean total application expenses per year were compared among specialties, and an analysis of variance was used to determine if the differences were statistically significant.

The number of applicants who recorded information in the Texas STAR database was 110 in 2021, 163 in 2022, 136 in 2023, and 129 in 2024.³ The total dermatology application expenses increased from $2805 in 2021 to $6231 in 2024; interview costs increased from $404 in 2021 to $911 in 2024; and away rotation costs increased from $850 in 2021 to $3812 in 2024 (all P<.05)(Table). There was no significant change in application fees during the study period ($2176 in 2021 to $2125 in 2024 [P=.58]). Dermatology had the fourth highest average total cost over the study period compared to all other specialties, increasing from $2250 in 2021 to $5250 in 2024, following orthopedic surgery ($2250 in 2021 to $6750 in 2024), plastic surgery ($2250 in 2021 to $9750 in 2024), and neurosurgery ($1750 in 2021 to $11,250 in 2024).

Our study found that dermatology residency application costs have increased significantly from 2021 to 2024, primarily driven by rising interview and away rotation expenses (both P<.05). This trend places dermatology among the most expensive fields to apply to for residency. A cross-sectional survey of dermatology residency program directors identified away rotations as one of the top 5 selection criteria, underscoring their importance in the matching process.⁴ In addition, a cross-sectional analysis of 345 dermatology residents found that 26.2% matched at institutions where they had mentors, including those they connected with through away rotations.^5,6 Overall, the high cost of away rotations partially may reflect the competitive nature of the specialty, as building connections at programs may enhance the chances of matching. These costs also can vary based on geography, as rotating in high-cost urban centers can be more expensive than in rural areas; however, rural rotations may be less common due to limited program availability and applicant preferences. For example, nearly 50% of 2024 Electronic Residency Application Service applicants indicated a preference for urban settings, while fewer than 5% selected rural settings.⁷ Additionally, the high costs associated with applying to residency programs and completing away rotations can disproportionately impact students from rural backgrounds and underrepresented minorities, who may have fewer financial resources.

In our study, the lower application-related expenses in 2021 (during the pandemic) compared to those of 2024 (postpandemic) likely stem from the Association of American Medical Colleges’ recommendation to conduct virtual interviews during the pandemic.⁸ In 2024, some dermatology programs returned to in-person interviews, with some applicants consequently incurring higher costs related to travel, lodging, and other associated expenses.⁸ A cost-analysis study of 4153 dermatology applicants from 2016 to 2021 found that the average application costs were $1759 per applicant during the pandemic, when virtual interviews replaced in-person ones, whereas costs were $8476 per applicant during periods with in-person interviews and no COVID-19 restrictions.² However, we did not observe a significant change in application fees over our study period, likely because the pandemic did not affect application numbers. A cross-sectional analysis of dermatology applicants during the pandemic similarly reported reductions in application-related expenses during the period when interviews were conducted virtually,⁹ supporting the trend observed in our study. Overall, our findings taken together with other studies highlight the pandemic’s role in reducing expenses and underscore the potential for exploring additional cost-saving measures.

Implementing strategies to reduce these financial burdens—including virtual interviews, increasing student funding for away rotations, and limiting the number of applications individual students can submit—could help alleviate socioeconomic disparities. The new signaling system for residency programs aims to reduce the number of applications submitted, as applicants typically receive interviews only from the limited number of programs they signal, reducing overall application costs. However, our data from the Texas STAR database suggest that application numbers remained relatively stable from 2021 to 2024, indicating that, despite signaling, many applicants still may apply broadly in hopes of improving their chances in an increasingly competitive field. Although a definitive solution to reducing the financial burden on dermatology applicants remains elusive, these strategies can raise awareness and encourage important dialogues.

Limitations of our study include the voluntary nature of the Texas STAR survey, leading to potential voluntary response bias, as well as the small sample size. Students who choose to submit cost data may differ systematically from those who do not; for example, students who match may be more likely to report their outcomes, while those who do not match may be less likely to participate, potentially introducing selection bias. In addition, general awareness of the Texas STAR survey may vary across institutions and among students, further limiting the number of students who participate. Additionally, 2021 was the only presignaling year included, making it difficult to assess longer-term trends. Despite these limitations, the Texas STAR database remains a valuable resource for analyzing general residency application expenses and trends, as it offers comprehensive data from more than 100 medical schools and includes many variables.³

In conclusion, our study found that total dermatology residency application costs have increased significantly from 2021 to 2024 (all P<.05), making dermatology among the most expensive specialties for applying. This study sets the foundation for future survey-based research for applicants and program directors on strategies to alleviate financial burdens.

Practice Gap

Pain during minimally invasive dermatologic procedures such as lidocaine injections, cryotherapy, nail unit injections, and cosmetic procedures including neurotoxin injections can cause patient discomfort leading to procedural anxiety, poor compliance with treatment regimens, and avoidance of necessary care. Current solutions to manage pain during dermatologic procedures present several limitations; for example, topical anesthetics seldom alleviate procedural pain,¹ particularly in sensitive areas (eg, nail unit, face) or for patients with a needle phobia. Additionally, topical anesthetics often require up to 2 hours to take effect, making them impractical for quick outpatient procedures. Other pain reduction strategies including vibration devices or cold sprays^2,3 can be effective but are an added expense to the physician or clinic, which may preclude their use in resource-limited settings. Psychological distraction techniques such as deep breathing require active patient participation and might reinforce pain expectations and increase patient anxiety.⁴ Given these challenges, there is a need for effective, affordable, nonpharmacologic pain reduction strategies that can be integrated seamlessly into clinical practice to enhance the patient experience.

The Technique

Tapping is a simple noninvasive distraction technique that may alleviate procedural pain by exploiting the gate control theory of pain.⁵ According to this theory, tactile stimuli activate mechanoreceptors that send inhibitory signals to the spinal cord, effectively closing the gate to pain transmission. Unlike the Helfer skin tap technique,⁶ which involves 15 preinjection taps and 3 postinjection taps directly on the injection site, our approach targets distant bony prominences. This modification allows for immediate needle insertion without interfering with the sterile field or increasing the risk for needlestick injuries from tapping near the injection site. Bony sites such as the shoulder or knee are ideal for this technique due to their high density and rigidity that efficiently transmit tactile stimuli––similar to how sound travels faster through solids than through liquids or gases.⁷

To implement this technique in practice, we first stabilize the injection site to reduce movement from tapping. This can be done by stabilizing the injection site (eg, resting the hand on an instrument stand during a nail unit injection). A second person—such as a medical assistant, medical student, resident, or even the patient’s family member—taps at a distant site at least an arm’s length away from the injection site (Figure). The tapping pressure should be firm enough for the patient to feel the vibration but not forceful enough that it becomes unpleasant or disrupts the injection area. Tapping starts just before needle insertion and continues through the injection. No warning is given to the patient, as the surprise element may help distract them from pain. Varying the rhythm, intensity, or location of the tapping can enhance its distracting effect. 

This tapping technique can be effectively combined with other pain reduction strategies in a multimodal approach; for example, when used concurrently with topical anesthetics, both the central (tapping) and peripheral (anesthetic) pain pathways are addressed, potentially yielding additive effects. For patients with a needle ­phobia, pairing tapping with cognitive distraction (eg, talkesthesia) may further reduce anxiety. In our nail specialty clinic at Weill Cornell Medicine (New York, New York), we often combine tapping with cold sprays and talkesthesia, which improves patient comfort without prolonging the visit. Importantly, the technique enables seamless integration with most pharmacologic and nonpharmacologic methods, eliminating the need for additional patient education or procedure time.

Practice Implications

The tapping technique described here is free, easy to implement, and requires no additional resources aside from another person to tap the patient during the procedure. It can be used for a wide range of dermatologic procedures, including biopsies, intralesional injections, and cosmetic treatments, including neurotoxin injections. The minimal learning curve and ease of integration into procedural workflows make this technique a valuable tool for dermatologists aiming to improve patient comfort without disrupting workflow. In our practice, we have observed that tapping reduces self-reported pain and helps ease anxiety, particularly in patients with a needle phobia. Its simplicity and accessibility make it a valuable addition to a wide range of dermatologic procedures. Prospective studies investigating patient-reported outcomes could help establish this technique’s role in clinical practice.

Practice Gap

Pain during minimally invasive dermatologic procedures such as lidocaine injections, cryotherapy, nail unit injections, and cosmetic procedures including neurotoxin injections can cause patient discomfort leading to procedural anxiety, poor compliance with treatment regimens, and avoidance of necessary care. Current solutions to manage pain during dermatologic procedures present several limitations; for example, topical anesthetics seldom alleviate procedural pain,¹ particularly in sensitive areas (eg, nail unit, face) or for patients with a needle phobia. Additionally, topical anesthetics often require up to 2 hours to take effect, making them impractical for quick outpatient procedures. Other pain reduction strategies including vibration devices or cold sprays^2,3 can be effective but are an added expense to the physician or clinic, which may preclude their use in resource-limited settings. Psychological distraction techniques such as deep breathing require active patient participation and might reinforce pain expectations and increase patient anxiety.⁴ Given these challenges, there is a need for effective, affordable, nonpharmacologic pain reduction strategies that can be integrated seamlessly into clinical practice to enhance the patient experience.

The Technique

Tapping is a simple noninvasive distraction technique that may alleviate procedural pain by exploiting the gate control theory of pain.⁵ According to this theory, tactile stimuli activate mechanoreceptors that send inhibitory signals to the spinal cord, effectively closing the gate to pain transmission. Unlike the Helfer skin tap technique,⁶ which involves 15 preinjection taps and 3 postinjection taps directly on the injection site, our approach targets distant bony prominences. This modification allows for immediate needle insertion without interfering with the sterile field or increasing the risk for needlestick injuries from tapping near the injection site. Bony sites such as the shoulder or knee are ideal for this technique due to their high density and rigidity that efficiently transmit tactile stimuli––similar to how sound travels faster through solids than through liquids or gases.⁷

To implement this technique in practice, we first stabilize the injection site to reduce movement from tapping. This can be done by stabilizing the injection site (eg, resting the hand on an instrument stand during a nail unit injection). A second person—such as a medical assistant, medical student, resident, or even the patient’s family member—taps at a distant site at least an arm’s length away from the injection site (Figure). The tapping pressure should be firm enough for the patient to feel the vibration but not forceful enough that it becomes unpleasant or disrupts the injection area. Tapping starts just before needle insertion and continues through the injection. No warning is given to the patient, as the surprise element may help distract them from pain. Varying the rhythm, intensity, or location of the tapping can enhance its distracting effect. 

This tapping technique can be effectively combined with other pain reduction strategies in a multimodal approach; for example, when used concurrently with topical anesthetics, both the central (tapping) and peripheral (anesthetic) pain pathways are addressed, potentially yielding additive effects. For patients with a needle ­phobia, pairing tapping with cognitive distraction (eg, talkesthesia) may further reduce anxiety. In our nail specialty clinic at Weill Cornell Medicine (New York, New York), we often combine tapping with cold sprays and talkesthesia, which improves patient comfort without prolonging the visit. Importantly, the technique enables seamless integration with most pharmacologic and nonpharmacologic methods, eliminating the need for additional patient education or procedure time.

Practice Implications

The tapping technique described here is free, easy to implement, and requires no additional resources aside from another person to tap the patient during the procedure. It can be used for a wide range of dermatologic procedures, including biopsies, intralesional injections, and cosmetic treatments, including neurotoxin injections. The minimal learning curve and ease of integration into procedural workflows make this technique a valuable tool for dermatologists aiming to improve patient comfort without disrupting workflow. In our practice, we have observed that tapping reduces self-reported pain and helps ease anxiety, particularly in patients with a needle phobia. Its simplicity and accessibility make it a valuable addition to a wide range of dermatologic procedures. Prospective studies investigating patient-reported outcomes could help establish this technique’s role in clinical practice.

Practice Gap

Pain during minimally invasive dermatologic procedures such as lidocaine injections, cryotherapy, nail unit injections, and cosmetic procedures including neurotoxin injections can cause patient discomfort leading to procedural anxiety, poor compliance with treatment regimens, and avoidance of necessary care. Current solutions to manage pain during dermatologic procedures present several limitations; for example, topical anesthetics seldom alleviate procedural pain,¹ particularly in sensitive areas (eg, nail unit, face) or for patients with a needle phobia. Additionally, topical anesthetics often require up to 2 hours to take effect, making them impractical for quick outpatient procedures. Other pain reduction strategies including vibration devices or cold sprays^2,3 can be effective but are an added expense to the physician or clinic, which may preclude their use in resource-limited settings. Psychological distraction techniques such as deep breathing require active patient participation and might reinforce pain expectations and increase patient anxiety.⁴ Given these challenges, there is a need for effective, affordable, nonpharmacologic pain reduction strategies that can be integrated seamlessly into clinical practice to enhance the patient experience.

The Technique

Tapping is a simple noninvasive distraction technique that may alleviate procedural pain by exploiting the gate control theory of pain.⁵ According to this theory, tactile stimuli activate mechanoreceptors that send inhibitory signals to the spinal cord, effectively closing the gate to pain transmission. Unlike the Helfer skin tap technique,⁶ which involves 15 preinjection taps and 3 postinjection taps directly on the injection site, our approach targets distant bony prominences. This modification allows for immediate needle insertion without interfering with the sterile field or increasing the risk for needlestick injuries from tapping near the injection site. Bony sites such as the shoulder or knee are ideal for this technique due to their high density and rigidity that efficiently transmit tactile stimuli––similar to how sound travels faster through solids than through liquids or gases.⁷

To implement this technique in practice, we first stabilize the injection site to reduce movement from tapping. This can be done by stabilizing the injection site (eg, resting the hand on an instrument stand during a nail unit injection). A second person—such as a medical assistant, medical student, resident, or even the patient’s family member—taps at a distant site at least an arm’s length away from the injection site (Figure). The tapping pressure should be firm enough for the patient to feel the vibration but not forceful enough that it becomes unpleasant or disrupts the injection area. Tapping starts just before needle insertion and continues through the injection. No warning is given to the patient, as the surprise element may help distract them from pain. Varying the rhythm, intensity, or location of the tapping can enhance its distracting effect. 

This tapping technique can be effectively combined with other pain reduction strategies in a multimodal approach; for example, when used concurrently with topical anesthetics, both the central (tapping) and peripheral (anesthetic) pain pathways are addressed, potentially yielding additive effects. For patients with a needle ­phobia, pairing tapping with cognitive distraction (eg, talkesthesia) may further reduce anxiety. In our nail specialty clinic at Weill Cornell Medicine (New York, New York), we often combine tapping with cold sprays and talkesthesia, which improves patient comfort without prolonging the visit. Importantly, the technique enables seamless integration with most pharmacologic and nonpharmacologic methods, eliminating the need for additional patient education or procedure time.

Practice Implications

The tapping technique described here is free, easy to implement, and requires no additional resources aside from another person to tap the patient during the procedure. It can be used for a wide range of dermatologic procedures, including biopsies, intralesional injections, and cosmetic treatments, including neurotoxin injections. The minimal learning curve and ease of integration into procedural workflows make this technique a valuable tool for dermatologists aiming to improve patient comfort without disrupting workflow. In our practice, we have observed that tapping reduces self-reported pain and helps ease anxiety, particularly in patients with a needle phobia. Its simplicity and accessibility make it a valuable addition to a wide range of dermatologic procedures. Prospective studies investigating patient-reported outcomes could help establish this technique’s role in clinical practice.