Botulinum toxin A for palmar hyperhidrosis

OBJECTIVE: We evaluated the efficacy and safety of intracutaneous injections of botulinum toxin A on severe palmar hyperhidrosis. METHODS: Ten patients with recalcitrant palmar hyperhidrosis were treated with intercutaneous injections of botulinum toxin A (Botox; 200 U for each hand). Patients were followed up to 23 months (mean +/- SD: 12.1 +/- 6.2 months). RESULTS Botulinum toxin significantly reduced abnormal sweating within 1 week in 100% of the patients. In six patients with a follow-up of 12 months or more the antisudorific effect lasted 12.3 +/- 5.5 months. The longest response duration was 22 months. Repeated treatment was performed in five patients with unchanged clinical efficacy. The only side-effect was tolerable pain from the intracutaneous injections in patients where a nerve block was not performed. CONCLUSIONS: Botulinum toxin A (200 U Botox per palm) was able to induce long-term remission in palmar hyperhidrosis without significant acute and long-term side-effects. Strictly intracutaneous injection of small volumes is recommended. So far, response to repeated treatments did not show evidence of neutralizing antibody induction.     

Treatment of focal hyperhidrosis with botulinum toxin type A: long-term follow-up in 61 patients

BACKGROUND: The blocking action of botulinum toxin type A (BTX-A) on cholinergically innervated sweat glands has been used successfully to treat patients with focal hyperhidrosis. OBJECTIVES: To investigate the long-term efficacy and safety of intradermal injections of BTX-A. METHODS: We performed an open-label study in 61 patients treated over a period of 3 years for axillary or palmar hyperhidrosis. A total dose of 400 mU BTX-A (Dysport) was injected into both axillae or 460 mU BTX-A (Dysport) into both palms. The injections were repeated after relapse. Objective quantification of sweat production was performed using digitized ninhydrin-stained sheets. RESULTS: Four weeks after BTX-A treatment the median reduction in sweat production was 71% compared with baseline (P < 0.001) in the axillary group and 42% (P = 0.005) in the palmar group. Subjective assessment of sweat production by the patients using a visual analogue scale (0, no sweating; 100, the most severe sweating) showed a significant reduction in both the axillary (P < 0.001) and palmar groups (P < 0.001). Secondary disturbances due to focal hyperhidrosis interfering with daily activities were markedly improved in both groups. The median time interval between the sets of injections was 34 weeks for axillary hyperhidrosis and 25 weeks for palmar hyperhidrosis. The treatment of palmar hyperhidrosis was complicated by transient but not disabling weakness of the small hand muscles in nine of 21 patients. CONCLUSIONS: Repeated intradermal injections of BTX-A in patients with axillary and palmar hyperhidrosis are as effective as first treatments.     

Botulinum toxin in dermatology - beyond wrinkles and sweat

Botulinum toxin (BTX) types A and B have been used with success in cosmetic dermatology and hyperhidrosis treatment. The present review focuses on other uses of BTX in dermatology. Discussed in particular are the available data on BTX in inflammatory diseases, proctology, and some other indications. From studies in various types of eczema, it seems that BTX-A not only acts as a potent inhibitor of acetylcholine but also as an inhibitor of substance P and of glutamate as well. By those mechanisms, BTX-A may be antipruritic, which may help explain the benefits of BTX-A in lichen simplex and dyshidrotic hand eczema. In Hailey-Hailey disease, facial eccrine hidrocystomas, salivary fistulas, and intrinsic rhinitis, BTX-A blocks the secretion of sweat/saliva/mucus. BTX-A has important applications in proctology where it has become the most powerful nonsurgical therapy for anal fissures. In proctalgia fugax and after hemorrhoidectomy, BTX-A is analgesic. Current treatment applications of BTX-A and its limitations are reviewed in this paper.     

Botulinum toxin dilution: our technique

The optimal dilution of botulinum toxin remains a controversial matter. With the use of botulinum toxin in new and more delicate indications, dilution is the main procedure to reduce side effects. The objective of this paper is to review the literature and report our dilution method and our experience.

We use either 500?U Dysport and 100?U Botox sterile vials. For facial indications we dilute them with 1?ml of sterile solution and in Dysport solution we add adrenalin with final solution 1:100.000. For platisma and dysidrosis we use more diluted solutions without adrenalin. It is very important to use a 30?U syringe to properly calibrate the low doses used.

Although there is a great variation in toxin dilution used by practitioners, in our opinion this particular aspect of the technique remains very important: using low amounts of toxin in very low amounts of salin solution reduces side effects. The use of adrenalin, such as for local anesthetic solutions, needs more study but may be useful to reduce doses, to minimalize spread in nearby muscles and, in our experience, does not produce side effects.     

Treatment of focal idiopathic hyperhidrosis with Botulinum Toxin Type A: clinical predictive factors of relapse‐free survival

Background No material about the identification of predictive clinical factors of therapeutic response to Botulinum Toxin Type A (BTX‐A) in focal idiopathic hyperhidrosis has been found. Objective To evaluate if age, sex, extension rate of hyperhidrotic area, localization, disease‐related impairment of life quality, number of previous local, non‐invasive treatments different from BTX‐A, and duration of disease, may affect the relapse‐free survival (RFS) after a BTX‐A treatment in palmar and axillary focal idiopathic hyperhidrosis. Methods Forty‐one patients suffering from palmar hyperhidrosis, and 38 patients suffering from axillary hyperhidrosis received intradermal injections of BTX‐A. All patients were clinically screened before and after treatment; they were followed for 15 months after it, according to Hyperhidrosis Disease Severity Scale (HDSS), Minor’s test, and DLQI test, to state disease severity, and disease‐related impairment of quality of life. Results The duration of therapeutic effect of BTX‐A is not significantly influenced by age (P = 0.783), sex (P = 0.762), extension of hyperhidrotic area (P = 0.770), site of involvement (P = 0.402), disease‐induced impairment of life quality (P = 0.745), number of previous therapies (P = 0.730), or site of involvement (P = 0.402). In palmar idiopathic hyperhidrosis, patients with a longer disease history show a shorter duration of RFS after a treatment with BTX‐A (P = 0.01). Conclusions Patients suffering from palmar hyperhidrosis have a longer lasting disease, and a length of disease more than 20 years in these patients influences the RFS after BTX‐A treatment.     

Treatment of palmar hyperhidrosis with botulinum toxin type A: 44 months of experience

Background Palmar hyperhidrosis (PH) can produce social and occupational difficulties and reduce the quality of life of those who suffer from this kind of problem. When dealing with focal hyperhidrosis, the patients’ attitudes and their subjective approaches regarding the process may influence the objective evaluation of the disorder. Objective To evaluate, by means of a scale, the subjective improvement of sweat production after treatment with botulinum toxin type A (BTX‐A) in a group of patients with severe, invalidating PH. Patients and methods Over a period of 44 months, 69 patients were treated and followed‐up, 27 patients had to be treated twice, and 11 patients required a third application; 80–100 U was injected in each palm. Regional nerve block was performed before the procedure. The patients were asked to evaluate their improvement at 1, 3, 6, 9, and 12 months of baseline. Results At 1 month, 53.6% of the patients reported an excellent improvement. Three months later, results were still excellent in 33.3% of the patients, and acceptable in 29%. From then on there was a statistically significant decrease of BTX‐A effectiveness. A second application was carried out at an interval of 7.5 ± 2.6 months, and a third one at 9 ± 4.4 months. The following complications could be observed: transitory weakness of hand muscles in 13 patients, wrist pain in 5 patients, and cramps in 1 patient. Conclusions Botulinum toxin is an effective alternative for the treatment of severe, invalidating PH. The maximum improvement persists up to 3 months; from then on, the effects slowly diminish. In our experience, there were no statistically significant differences with further applications of BTX‐A. The patients’ subjective assessment can be used to evaluate the sweat production after treatment with BTX‐A in those medical centers where a more objective evaluation becomes difficult or impossible.     

A型肉毒毒素消除面部皱纹100例临床观察

目的：观察A型肉毒毒素(BTXA)去除面部皱纹的疗效，探讨BTXA皮肤除皱的方法及降低药物副作用的发生。方法：对100例患者应用BTXA局部多点注射。结果：面部皮肤除皱有效率100％，皮纹变浅、变平而且光滑，效果通常持续3～6个月。局部副作用轻微、短暂且可自行消失，无全身不良反应。结论：注射BTXA是暂时性消除面部皱纹的安全、有效、简便的治疗方法，但应注意操作规程及适当剂量。     

Subcutaneous curettage vs. injection of botulinum toxin A for treatment of axillary hyperhidrosis.

BACKGROUND: Axillary hyperhidrosis is a functional non-inflammatory abnormality of the eccrine sweat glands. The cause of genuine hyperhidrosis is unknown and, therefore, no specific corrective therapy is available and conservative treatment often fails. Subcutaneous sweat gland curettage of the axillae is one of the proven surgical modalities. Local injection of botulinum toxin A (BT-A) is a promising new conservative approach. OBJECTIVE: The purpose of this study was to compare the efficacy of subcutaneous curettage vs. injection of BT-A in axillary hyperhidrosis. METHODS: A total of 113 patients (36.3% males, 63.7% females) suffering from genuine axillary hyperhidrosis were treated by either subcutaneous curettage (n = 90) or local injection of BT-A (n = 23). Median follow-up period was 23.5 months. Questionnaires were handed out to patients for a subjective assessment of symptoms before treatment, 6 months after the procedure, and at the time of last follow-up. The patients were asked to rate the amount of axillary sweating based on a score ranging from 1 (no axillary secretion) to 6 (maximum axillary secretion). The subjective scores of sweating at rest, at high temperatures, under physical stress, under emotional stress and after spicy meals were assessed. RESULTS: The patients' subjective assessments of the overall outcome after subcutaneous curettage were 'very good' in 36.4%, 'good' in 29.9% and 'satisfactory' in 16.9%. The subjective score of axillary sweating at rest was reduced to 40.0% after 6 months, and finally to 45.7% at the end of follow-up (median: 28.2 months). Patients treated by BT-A injection assessed outcome as 'very good' in 39.1%, 'good' in 21.7% and 'satisfactory' in 8.7%. Sweating at rest was reduced to 48.5% after 6 months, and finally to 68.8% at the end of follow-up (median: 16.1 months). The mean duration of the antiperspiration effect of BT-A was 7.6 months (median: 7 months), but there were two cases of long durations, i.e. 14 and 18 months. CONCLUSIONS: Subcutaneous curettage and injection of BT-A both present major advantages compared with earlier methods. Subcutaneous curettage offers the same permanent efficacy but far fewer side-effects than sympathectomy, and less scarring than local excisional procedures, respectively. Of the conservative approaches BT-A is by far the most efficacious. Patients should be informed of the advantages and disadvantages of both methods.     

Botulinum toxin for periocular lines: the single-injection technique

Background Botulinum is a well established treatment for facial wrinkles and hyperfunctional lines, including those at the periocular area. Objective To illustrate a simple periocular injection technique. It differs from the usual one since it is a single injection, instead of several. Methods Thirty consecutive patients were treated with this technique on one side, and the standard multipuncture technique on the contralateral side. Each patient, being their own control, received 10–12 Botox units to each side. The orbicularis oculi muscle was injected using two different types of needles: a standard 30 g 13 mm needle for the multipunctured side and a 30 g 25 mm needle for the single puncture side. Follow up assessments were made on days 7, 15 and 120. Results Good results were achieved in all patients. No relevant cosmetic difference was noticeable between the two sides. The pharmacological effect lasted about 5 months, with no difference between the two techniques. Both techniques were safe and caused the same amount of bruising. The single injection was preferred by patients. The single‐injection technique, on the other hand, requires more skill and experience by the operator. Conclusions The single‐injection technique for periocular lines is a useful alternative to the standard multipuncture technique. It reduces patients’ discomfort.     

Therapeutic effectiveness of botulinum toxin type A based on severity of palmar hyperhidrosis

A dose of 60 units (U) of botulinum toxin type A (BT-A) has been confirmed to have efficacy for patients with palmoplantar hyperhidrosis. However, the effectiveness of this dose is limited in severe cases defined as sweat production of 2 mg/cm(2) per min or more (measured by the ventilated capsule method) and a Hyperhidrosis Disease Severity Scale (HDSS) grade of 3 or 4. An increased dose of 90 U of BT-A was found to reduce sweating for approximately 7 months. In a comparison of patients with sweat production of more than 2.5 mg/cm(2) per min and an HDSS grade of 4 and patients with sweat production of 2.5 mg/cm(2) per min or less and an HDSS grade of 3, there was no difference in the reduction of sweat production at 5 months, but the duration of the reduced sweating was shorter for the former group. This suggests that there are limits to the efficacy of BT-A for severe forms of the disease with sweat production of more than 2.5 mg/cm(2) per mL.     

Efficacy of botulinum toxin in pachyonychia congenita type 1: report of two new cases

Pachyonychia congenita (PC) is a rare genodermatosis caused by a mutation in keratin genes, which can lead to hypertrophic nail dystrophy and focal palmoplantar keratoderma (predominantly plantar), amongst other manifestations. Painful blisters and callosities, sometimes exacerbated by hyperhidrosis, are major issues that can have a significant impact on patient quality of life. Many alternative treatments for this condition have been applied with variable and partial clinical response, but a definitive cure for this disease has yet to be discovered. After obtaining informed consent, two patients with genetically confirmed PC type 1 were treated with plantar injections of botulinum toxin type A. Both patients showed a marked improvement in pain and blistering with an average response time of one week, a six‐month mean duration of effectiveness, and a lack of any side effects or tachyphylaxis.     

Botulinum toxin type A reduces histamine-induced itch and vasomotor responses in human skin

Background Clinical evidence has revealed the antipruritic effect of botulinum toxin type A (BoNT/A). BoNT/A is believed to be effective against itch as it inhibits the release of acetylcholine as well as some other substances that may be involved in itch. Objectives To investigate the effect of subcutaneous administration of BoNT/A on experimentally histamine‐induced itch in human skin. Methods In this double‐blind, placebo‐controlled study, 14 healthy men (mean ± SD age 26·3 ± 2·6 years) received BoNT/A (Botox^®; Allergan, Irvine, CA, U.S.A.; 5 U) and isotonic saline on the volar surface of either forearm. Histamine prick tests were performed four times at the treatment sites (before treatment, and days 1, 3 and 7 after treatment). The itch intensity (as rated on a 0–10 visual analogue scale), itch area, neurogenic inflammation (visible flare area), blood flow (laser Doppler) and cutaneous temperature (thermographic images) were measured over the course of the trials. Results BoNT/A reduced the histamine‐induced itch intensity (F_1,39 = 30·2, P < 0·001) and itch area (F_1,39 = 8·8, P = 0·011) compared with saline at all time points after treatment. The duration of itch was also shorter for BoNT/A‐treated areas (F_1,39 = 19·4, P < 0·001), with a peak effect at day 7. The flare area was smaller in the BoNT/A‐treated arm compared with the saline‐treated arm at all time points after treatment (F_1,39 = 15·4, P = 0·002). Findings from blood flow (F_1,26 = 177·3, P < 0·001) and temperature measurements (F_1,26 = 27·6, P < 0·001) clearly showed the suppressive effect of BoNT/A on vasomotor reactions, with the maximal effect on days 3 and 7. Conclusions BoNT/A reduced the itch intensity, blood flow and neurogenic inflammation in response to the histamine prick test in human skin. The findings could be applicable in the treatment of some pruritic conditions that can be difficult to treat with conventional treatments.     

A randomized, double-blind, placebo-controlled trial of botulinum A toxin for severe axillary hyperhidrosis

Excessive axillary hyperhidrosis is a socially embarrassing condition which severely reduces quality of life and may result in psychological disturbance. Available treatment strategies do not resolve the problem in all cases. Intracutaneous injections of botulinum A toxin have been shown to be effective in patients with local sweating disorders. We performed a randomized, double-blind, within-group comparison in 13 individuals (nine women and four men) with severe axillary hyperhidrosis resistant to conventional treatment, to study the effect of intracutaneous injections of botulinum toxin on sweating. A total dose of 200 mouse units of botulinum A toxin (Dysport(R)) was injected into six different sites in one axilla, whereas the other was injected with sterile saline. Objective quantification of sweat production was performed using digitized ninhydrin-stained sheets. Three weeks after treatment, the mean difference in ninhydrin staining between botulinum-treated and placebo-treated axillae was -34.5% (P < 0.001), after 8 weeks -36.9% (P < 0.001) and after 13 weeks -28.4% (P < 0.001). Subjective rating of sweat production was evaluated on a visual analogue scale (0, no sweating, to 100, most severe sweating). Three weeks after treatment the difference between the botulinum-treated and placebo-treated axillae was -56.5% (P < 0.001), after 8 weeks -67.4% (P < 0.001) and after 13 weeks -62.5% (P < 0.001). No serious side-effects were observed.     

The place of botulinum toxin type A in the treatment of focal hyperhidrosis

BACKGROUND: Hyperhidrosis (primary or secondary) is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patient's quality of life. IMPACT OF DISEASE: Objective evaluation comprising quantitative assessment (gravimetric and Minor's iodine starch test) and subjective evaluation (Dermatology Quality of Life Index and Hyperhidrosis Impact Questionnaire) allow accurate assessment of the impact of hyperhidrosis on patients. BOTULINUM TOXIN TYPE A: Botulinum toxin type A acts by inhibiting the release of acetylcholine at the presynaptic membrane of cholinergic neurones. It has proved useful in treating a number of diseases relating to muscular dystonia and is now proving beneficial in treating hyperhidrosis. Clinical trials investigating botulinum toxin type A use in axillary and palmar hyperhidrosis show significant benefits with few side-effects reported, with a favourable impact also being seen on patient quality of life. Botulinum toxin type A injections are generally well-tolerated with beneficial results lasting from 4 to 16 months. CONCLUSIONS: Botulinum toxin type A injections are an effective and well-tolerated treatment for hyperhidrosis. This paper proposes a positioning of this treatment along with current established treatments, and highlights the role of botulinum toxin type A as a valuable therapy for the treatment of hyperhidrosis.     

Treatment of pachyonychia congenita with plantar injections of botulinum toxin

Pachyonychia congenita (PC) is a rare genodermatosis which may be associated with painful, focal hyperkeratosis on the soles. Plantar sweating at high ambient temperatures increases the blistering of the callosities. We report three patients with PC who had great problems in walking, especially during summer time. They were treated with intracutaneous plantar injections of botulinum toxin type A (Dysport, 100 U mL(-1); Ipsen, Slough, U.K.) after prior intravenous regional anaesthesia of the foot with a low tourniquet and 25 mL prilocaine (5 mg mL(-1)). Within a week all three patients experienced dryness and a remarkable relief of pain from plantar pressure sites. The effect duration was 6 weeks to 6 months. Repeated injections over a 2-year period confirmed the good results, with no side-effects or tachyphylaxis noted.     

Botulinum toxin cosmetic therapy correlates with a more positive mood

Background  It has been suggested that botulinum toxin A (BTX-A) treatment for frown lines can also be used as a treatment for depression. A psychological mechanism for this effect is reviewed in which paralysis of the corrugator (frown) muscles leads to less facial feedback for negative emotions. Consequently, a negative affect is harder to maintain and so the person has a more positive mood.
Methods  In order to test this mechanism, the mood of patients who had received BTX-A treatment for glabelar frown lines was measured and compared with patients who had received other cosmetic treatments.
Results  The BTX-A–treated patients showed significantly less negative mood.
Conclusion  The results support the facial feedback view that frowning can make one unhappier. Treatments that prevent frowning correlate with reduced negative mood.     

Local injection of botulinum toxin A for palmar hyperhidrosis: usefulness and efficacy in relation to severity

Botulinum toxin A is widely used in Europe and the USA for the treatment of localized hyperhidrosis, and its efficacy has been recognized. In this study, botulinum toxin A (Botox) was locally injected at 30 sites (2 U/injection) on the right palm in 27 patients with palmar hyperhidrosis (14 severe patients, 13 mild patients), and the results confirmed the efficacy of injection. The amount of sweat was then quantified for the left and right hands every month after local injection. The quantity of sweat on the treated hand was approximately one-fifth that on the untreated hand. In addition, the quantity of sweat on the untreated hand decreased slightly. Over time, the quantity of sweat on the treated hand increased slightly, but the quantity of sweat on the treated hand at 6 months after injection was less than half that before injection, and there were significant differences before and after injection. In the present study, severe sweating was defined as 1 mg/cm2/min or more and mild sweating as less than 1 mg/cm2/min, and the therapeutic effects of botulinum toxin A were analyzed in relation to severity. When compared to the mild cases, the quantity of sweat remained higher in the severe cases after botulinum toxin A therapy. Therefore, to achieve satisfactory effects in severe cases, it would be necessary to increase the number of injection sites, as well as injection dose.