Share this article on:

The Use of a Topical Skin Cooling Device to Achieve Relief of Injection-Induced Pain

Seo, Dong Wan M.D.; Hong, Joon Pio M.D., Ph.D., M.M.M.

Plastic and Reconstructive Surgery: March 2009 - Volume 123 - Issue 3 - p 111e-112e
doi: 10.1097/PRS.0b013e31819c18e7

Department of Plastic Surgery; Asan Medical Center; University of Ulsan College of Medicine; Seoul, Korea

Correspondence to Dr. Hong; Department of Plastic Surgery; Asan Medical Center; University of Ulsan; Songpa-gu, Poongnap2-dong, 388-1; Seoul, Korea 138-736;

Back to Top | Article Outline


The number of office procedures involving a needle-based approach using botulinum toxins and various fillers is increasing steadily. Other procedures that may induce pain in an office setting can be laser treatments and chemical peelings. However, despite the dramatic results these office-based procedures provide, there are some complaints of pain, which may lead to refusal of repeated sessions.1,2

The purpose of this study was to determine the efficacy of a skin-cooling device against injection-related pain. This prospective study involved a total of 50 patients injected with botulinum toxin on the bilateral periorbital region. The patients were divided into three treatment groups. Group 1 was treated with the topical skin-cooling device (metallic plate constant at –8°C applied on the skin before each injection for a duration of 6 seconds) on one side, and the other side served as a control (n = 15). Group 2 was treated with topical anesthetic cream [EMLA (eutectic mixture of lidocaine and prilocaine) applied 60 minutes before injection] on one side, and the other side served as a control (n = 15). Group 3 was treated with a skin-cooling device on one side, and the other side was treated with anesthetic cream (n = 20). A visual analogue scale was used to measure pain intensity to compare both sides. In group 1, the average pain score on the skin-cooling device was 1.8 compared with 2.8 on the control side (p < 0.005). In group 2, the average pain score on the topical anesthetic side was 2 compared with 3.13 on the control side (p < 0.006). In group 3, the average pain score with the skin-cooling device (CoolSkin; Elbio, Seoul, Korea) was 2.9 compared with 2.4 on the side treated with topical anesthetics, which was not statistically significant (p = 0.213) (Fig. 1).

Fig. 1.

Fig. 1.

The skin-cooling device uses the concept of the Peltier effect, resulting in thermoelectric refrigeration. When electric current flows through the Peltier element, one side is heated and the other side becomes cold. The cold plate is maintained at a temperature of –8°C. Contact with the cold surface for 6 seconds leads to a rapid drop in skin temperature at 9 ± 3°C, causing the anesthetic effect (Fig. 2). The effect of CoolSkin when compared with control demonstrated a significant decrease in pain and, when compared with topical EMLA cream, demonstrated similar efficacy. This can be explained by the effect of cold on sensory nociceptors, decreased conduction time, and synaptic activity in peripheral nerves.3 The sensory conduction velocity showed an 18.3 percent decrease after 16 minutes of ice application.3 The alternation of nerve velocity begins at 27°C, and analgesia can be achieved at 13.6°C skin temperature when tested with pin prick.4 It has also been reported that nerve transmission ceases between 9°C and 18°C, and it takes approximately 9 minutes of ice application to achieve this temperature.5 When the temperature of the skin rises back to 15.6°C, the pain returns when pricked with a pin.4

Fig. 2.

Fig. 2.

In conclusion, the skin-cooling device, by achieving a sudden and brief temperature of the skin at 9 ± 3°C, significantly decreases injection-related pain.

Dong Wan Seo, M.D.

Joon Pio Hong, M.D., Ph.D., M.M.M.

Department of Plastic Surgery

Asan Medical Center

University of Ulsan College of Medicine

Seoul, Korea

Back to Top | Article Outline


This study was supported, in part, by the Daewoong Pharmaceutical Co.

Back to Top | Article Outline


1. Dutton JJ. Botulinum A toxin in the treatment of craniocervical muscle spasms: Short and long-term, local and systemic effects. Surv Ophthalmol. 1996;41:51–65.
2. Grandas F, Elston J, Quinn N, Marsden CD. Blepharospasm: A review of 264 patients. J Neurol Neurosurg Psychiatry 1988 51:767–772.
3. Lee JM, Warren MP, Manson SM. Effect of ice on nerve conduction velocity. Physiotherapy 1978;64:2.
4. Bugaj R. The cooling, analgesic, and rewarming effects of ice massage on localized skin. Phys Ther. 1975;55:11–19.
5. Kanlayanaphotporn R, Janwantanakul P. Comparison of skin surface temperature during the application of various cryotherapy modalities. Arch Phys Med Rehabil. 2005;86:1411–1415.
Back to Top | Article Outline

Section Description


Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-avail able basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ en kwell, at We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be d isclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to pub lish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect t he policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons