Prospective Open-Label Study of Botulinum Toxin Type A in Patients with Axillary Hyperhidrosis: Effects on Functional Impairment and Quality of Life

BACKGROUND: Patients with primary axillary hyperhidrosis experience substantial functional impairment and reduced health-related quality of life (HRQOL). Few studies have comprehensively evaluated the effects of botulinum toxin type A (BoNT-A) on these symptoms. OBJECTIVE: To prospectively assess the effects of BoNT-A on functional impairment associated with primary axillary hyperhidrosis. METHODS: Patients treated with BoNT-A 50 U per axilla at baseline were assessed 4 and 12 weeks later. Outcome measures included functional impairment as assessed by the Hyperhidrosis Disease Severity Scale and the Hyperhidrosis Impact Questionnaire and dermatology-specific HRQOL as assessed by the Dermatology Life Quality Index. RESULTS: At weeks 4 and 12 after BoNT-A treatment, 85% and 90% of patients achieved the a priori definition of treatment responder. Patients reported less occupational and emotional impairment, spent less time managing their hyperhidrosis, and had fewer difficulties in social situations. Adverse events were uncommon (5.5%), were mild, and did not require treatment. At study end, 53% of patients reported no dermatology-specific HRQOL impairment and 90% were satisfied with treatment. CONCLUSIONS: Significant, meaningful, rapid, and durable reductions in disease severity and functional impairment, as well as improvements in HRQOL, were seen following BoNT-A treatment. BoNT-A was safe and well tolerated, producing high levels of patient satisfaction.     

The Island Pedicle Flap

Background. Surgical defects following the extirpation of cutaneous neoplasia may present challenges to the dermatologic surgeon. There are many repair options for an individual defect, including second-intention healing, primary closure, skin graft, and skin flap closure. The island pedicle flap is a random pattern advancement flap well suited to reconstruct a variety of small- to intermediate-sized soft tissue wounds.
Objective. To review the utility of the island pedicle flap in reconstructive dermatologic surgery and to detail the operative technique to achieve reproducible functional and esthetic results.
Methods. The method of flap reconstruction is presented. A variety of defects repaired with this technique are reviewed.
Results. The subcutaneous island pedicle flap yielded excellent functional and cosmetic repair of the presented defects with minimal operative morbidity. Secondary to a well-preserved central vascular pedicle, complications are infrequent.
Conclusions. The random pattern island pedicle flap is a versatile and robust flap used to repair a variety of soft tissue wounds in a single-stage procedure with reproducible operative outcomes.     

Use of the Z-Plasty Technique for Forehead Defects

BACKGROUND: Surgical defects of the forehead are commonplace for the Mohs surgeon. The relaxed skin tension lines (RSTLs) of this region allow for repairs ranging from direct linear closures to more complex advancement flaps. Defects in which the longitudinal axis orients perpendicular to the RSTLs, whether secondary to wound shape or ease of tissue movement, present a somewhat more challenging problem. OBJECTIVE: To describe the use of the Z-plasty in repairing forehead surgical defects. METHOD: We illustrate two Mohs surgical cases in which the size and location of the forehead defect did not allow for a straightforward and cosmetically acceptable closure. Tissue mobility and defect shape permitted design and implementation of a Z-plasty. RESULTS: Use of the Z-plasty technique allowed a portion of the vertical incision line to be reoriented within the forehead RSTLs, producing a favorable cosmetic outcome. CONCLUSION: Forehead defects that are shaped such that the long axis is perpendicular to the RSTLs or located in a region where tissue mobility more easily permits a vertical closure can present a challenge for the reconstructive surgeon. Knowledge of tissue mechanics and use of rotation and advancement make the Z-plasty a favorable option in many of these situations.     

Hyperoxia improves microvascular perfusion in a murine wound model

There is a need for a noninvasive method that measures wound angiogenesis. Hyperoxia is known to increase the appearance of new blood vessels in wounds, yet no study has confirmed increases in wound bed perfusion with periodic hyperbaric oxygen (HBO) exposure. This study investigates whether laser Doppler imaging is able to detect and quantify the enhancement of wound angiogenesis that is known to occur with intermittent HBO treatments. Full-thickness dorsal dermal wounds were created on mice randomized to hyperoxic (n = 14) and control (n = 15) groups. Hyperbaric oxygen was administered twice daily for 90 minutes each at 2.1 atmospheres for 7 days. Wound bed perfusion was measured by laser Doppler imaging on days 0, 7, and 10 postwounding. Wound blood flow increased significantly over baseline on day 7 and 10 in the hyperoxic group, but only on day 10 in the control group. Comparison between groups showed a 20% statistically significant increase in wound perfusion in HBO-treated animals compared to control on day 10 (p = 0.05). Laser Doppler imaging was able to detect and quantify the increase in wound bed perfusion resulting from intermittent HBO treatments and shows promise as a noninvasive measure of angiogenesis and wound healing.     

Botulinum Toxin A in the Treatment of Chromhidrosis

Background. Chromhidrosis is an uncommon disorder characterized by secretion of colored sweat by apocrine glands, typically localized to the face or axilla. The current treatments available for chromhidrosis are time consuming and frequently ineffective.
Objective. Our purpose is to demonstrate a novel approach to the treatment of apocrine chromhidrosis.
Methods. We report a case of apocrine chromhidrosis successfully treated with botulinum toxin A (BTX-A; Botox).
Results. BTX-A therapy successfully controlled facial chromhidrosis, and the effects were visible at 19 weeks post-treatment. The therapeutic benefits may be attributed to its inhibitory effects on cholinergic stimulation, adrenergic stimulation, and substance P release, although further studies are necessary to elucidate the precise mechanism of action.
Conclusion. This report demonstrates a new therapeutic approach to patients suffering from chromhidrosis.     

Dose-Ranging Study of Botulinum Toxin Type A in the Treatment of Glabellar Rhytids in Females

OBJECTIVE: To compare the efficacy, safety, and duration of effect of four doses of botulinum toxin type A in the treatment of glabellar rhytids in females. DESIGN: Double-blind, randomized, parallel-group, dose-ranging trial followed by an open-label extension. SETTING: Private dermatologic clinic. SUBJECTS: Eighty female subjects with moderate to severe wrinkles at maximum frown entered the study. The first 40 subjects completing the double-blind phase entered the open-label extension. INTERVENTION: Random administration of 10, 20, 30, or 40 U botulinum toxin type A in divided doses. Open-label trial: 30 U botulinum toxin type A at the same sites in divided doses. MAIN OUTCOME MEASUREMENTS: Trained observer and subject assessments of wrinkle severity at maximum frown and repose using the Facial Wrinkle Scale (0 = none to 3 = severe), subject satisfaction, and adverse events. Follow-up monthly for up to 1 year postinjection. RESULTS: Relapse rates and responder rates revealed benefits lasting 3 to 6 months or longer. Objectively, 10 U of botulinum toxin type A was significantly less effective than 20, 30, or 40 U. The relapse rate at 4 months was significantly higher in the 10 U group (83%) versus 40, 30, or 20 U (28%, 30%, and 33%, respectively). Subject satisfaction was high in all groups. Duration of effect and response rates were sustained during the open-label extension. Adverse effects were mild and infrequent. CONCLUSION: Twenty to 40 U botulinum toxin type A doses were significantly more effective at reducing glabellar lines than 10 U. Most subjects experienced benefits for 3 to 4 months; some subjects demonstrated effect for up to 12 months.