Botulinum toxin-B and the management of hyperhidrosis

Study on botulinum toxin in dermatology from 2000 to 2023: A CiteSpace-based bibliometric analyses

OBJECTIVE

Using bibliometric methods, this study analyzed and summarized the current situation and development of the global application of botulinum toxin in dermatology.

METHODS

Literature published in the Web of Science Core Collection database from January 1, 2000 to October 28, 2023 was searched for topics such as "Botulinum toxin," "Dermatology," and so forth. The number of publications, countries, institutions, journals, authors, cited literature, keywords, and so forth, were analyzed and a visual knowledge map was created using scientometric tools such as CiteSpace, VOSviewer, and Scimago Graphica.

RESULTS

A total of 2039 documents were retrieved and 1877 documents were included after de-duplication and transformation. The country with the highest number of published periodical articles was the United States; the main research institution was Yonsei University; the author with the highest number of published periodical articles was Kim, Hee Jin; and the high-frequency keywords mainly related to indications, combination therapy, and safety optimization.

CONCLUSION

The results of this study provide information on the current status and trends in clinical studies of botulinum toxin in dermatology, which will help researchers identify hotspots and explore new research directions in this field.

RimabotulinumtoxinB: An Update

BACKGROUND

Botulinum type-A toxin is a well established aesthetic and medical treatment. While the usage of type-B toxin is less common, there is a growing interest in using type-B toxin, especially in those who are treatment resistant.

OBJECTIVE

To evaluate the primary FDA-approved clinical applications of rimabotulinumtoxinB, along with established and emerging off-label clinical indications.

MATERIAL AND METHODS

Articles were reviewed from PubMed database and Food and Drug Adminstration guidelines.

RESULTS

Facial rhytids tend to use a higher conversion ratio between type A and type B toxin, due to type B toxin's weaker affinity to muscles and higher affinity for sweat glands. Specially, a 1:100 to 1:50 ratio was utilized for glabellar rhytids, a 1:25 to 1:50 ratio for periocular rhytids, a 1:50 to 1:66.6 ratio for cervical dystonia, a 1:20 to 1:50 ratio for hyperhidrosis, and a 1:25 to 30 ratio for sialorrhea.

CONCLUSION

Type B toxin has demonstrated its safety and efficacy in treating facial rhytids, cervical dystonia, sialorrhea and hyperhidrosis, with potential for novel applications under investigation. Regardless of injection location and clinical applications, dry mouth and dysphagia remained the most common side effects. Across all indications, type B toxin appeared to have a faster onset of action, a dose-dependent clinical duration, and a dose-dependent adverse effect profile.

Efficacy and Safety of Botulinum Toxin B in Focal Hyperhidrosis: A Narrative Review

Botulinum toxin type B (BoNT-B), known as Myobloc® in the United States and as Neurobloc® in Europe, is a new therapeutically available serotype among the botulinum toxin family. During the last years several data have been reported in literature investigating its efficacy and safety, as well as defining the dosing and application regiments of BoNT-B in the treatment of hyperhidrosis. Moreover, recent studies have been examining its safety profile, which may be different from those known about BoNT-A. The aim of this review is to provide information about what is currently known about BoNT-B in regards to the treatment of focal hyperhidrosis.

Botulinum toxin: Pharmacology and injectable administration for the treatment of primary hyperhidrosis

Hyperhidrosis is a dermatological condition defined by excessive sweating beyond thermoregulatory needs with significant effects on patients' quality of life. Hyperhidrosis is categorized as primary or secondary: primary hyperhidrosis is mostly focal and idiopathic, whereas secondary hyperhidrosis is commonly generalized and caused by an underlying medical condition or use of medications. Various surgical and nonsurgical therapies exist for primary hyperhidrosis. Although botulinum toxin is one of the deadliest toxins known, when used in small doses, it is one of the most effective therapies for primary hyperhidrosis. Botulinum toxin injections are widely used as a second-line primary hyperhidrosis treatment option once topical treatment strategies have failed. This article provides an overview of the commercially available botulinum toxin formulations and their applications in the treatment of primary hyperhidrosis.

The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options

Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.

Botulinum Toxin A and B: A Comparative Dosing Study for Spasmodic Dysphonia

OBJECTIVE: The purpose of this study was to find the conversion factor, safety, and efficacy of type A to type B toxin for laryngeal muscles.

METHODS: Thirty-two patients with adductor spasmodic dysphonia with stable doses of A toxin to manage their symptom were given type B toxin starting at a conversion of 1 Uof BTX-A to 50 U of BTX-B. The patients were followed for 1 year, and doses adjusted according to response.

RESULTS: The conversion factor was found to be 52.3 U:1 U. The onset of action of type B was more rapid (2.09 days vs 3.2 days [ P = 0.028]), with a shorter duration of benefit (10.8 weeks vs 17 weeks [ P = 0.002). The safety profile for A and B toxin appeared the same, with 3 patients receiving Myobloc reporting dry mouth.

CONCLUSION: This study shows that a conversion factor of 52.3:1 Myobloc (BTX-B) to Botox (BTX-A) and that Myobloc is an effective alternative to Botox (BTX-A) for patients with spasmodic dysphonia.

EBM RATING: B-2

Efficacy of botulinum toxin type B for the treatment of primary palmar hyperhidrosis: a prospective, open, single-blind, multi-centre study

Primary palmar hyperhidrosis is a distressing and disabling condition that can produce social, psychological and occupational problems. Although the use of botulinum toxin type A (BoNT-A) has been reported as an efficacious and safe intervention to improve palmar hyperhidrosis, only one study concerned botulinum toxin type B (BoNT-B) in this disorder. The aim of study was to evaluate the efficacy and safety of BoNT-B in treating primary palmar hyperhidrosis. Participants were injected with 5,000 IU of BoNT-B in each palm. Visual analogue test (VAS) to evaluate the intensity of decrease in sweat production, Minor's iodine starch test and measurement of paper towels' weight were used to ascertain palmar sweating at baseline, 4, 12 and 24 weeks after BoNT-B injections by a blind examiner. Thirty-two subjects (12 males, 20 females, mean age 31 ± 11) were enrolled. Significant reduction of palmar sweating was detected after BoNT-B injection: 2.9 ± 1.4, 0.3 ± 0.4, 0.9 ± 0.8, and 2.1 ± 1.5 g (p < 0.001) of paper towels' weight for the right palm at baseline, 4, 12 and 24 weeks; and 2.8 ± 1.7, 0.5 ± 0.6, 0.8 ± 0.7, and 1.8 ± 1.25 g (p < 0.001) at same time, respectively for the left palm. Significant reduction of mean VAS values were also detected after BoNT-B injections: 8.6 ± 1.1, 0.6 ± 0.8, 3.5 ± 2.5, and 7.1 ± 2.4 (p < 0.0001) at baseline, 4, 12 and 24 weeks, respectively. Mild side effects consisting in local pain and hand weakness were observed in 4 (12.5%) subjects. The findings indicated that the use of 5,000 IU BoNT-B injection in each palm was safe and significantly improved the severity of palmar hyperhidrosis.

Primary pediatric hyperhidrosis: a review of current treatment options

Hyperhidrosis is a disorder of excessive sweating beyond what is physiologically necessary for thermoregulation. Primary hyperhidrosis is localized; it can affect the axillae, palms, soles, face, and other areas and is idiopathic. The prevalence of hyperhidrosis in the United States is estimated to be 2.8% of the population, with about one-half (1.4%) of these individuals having the axillary form. Hyperhidrosis occurs in both children and adults, with the average age of onset of primary hyperhidrosis being 14-25 years. This disorder can be detrimental to a patient's social, professional, psychological, and physical well-being. Early detection and management can significantly improve a patient's quality of life, yet hyperhidrosis remains widely under diagnosed and under treated, particularly among pediatric patients. The purpose of this article is to review the treatment of pediatric hyperhidrosis, and to increase awareness and inspire further research on this important and often overlooked medical problem.

Treatment of focal hyperhidrosis

BACKGROUND

Focal hyperhidrosis is not rare, affecting over 2.5% of the population. This condition is often socially and professionally debilitating, leading to significant quality of life impairment. It most commonly involves the axillae, palms, soles, and face.

OBJECTIVE

To review hyperhidrosis and discuss and compare the treatment options currently available.

CONCLUSIONS

Topical or systemic therapies may be helpful for patients with mild disease. Invasive surgical options, although often effective, are limited by complications. More recently, botulinum toxin injection has proven to be a safe and successful treatment for hyperhidrosis and results in high patient satisfaction. Botulinum toxin A (Botox, Allergan Inc., Irvine, CA) is currently approved in the United States, Canada, the United Kingdom, and many other countries for the treatment of axillary hyperhidrosis and is routinely used off-label for other anatomic sites.

Diagnosis, Impact, and Management of Focal Hyperhidrosis: Treatment Review Including Botulinum Toxin Therapy

Idiopathic localized hyperhidrosis, called for hyperhidrosis, affects almost 3% of the US population. The most frequent anatomic sites of involvement include the axillae, palms, soles, and face. For those affected, this condition can be extremely socially debilitating and interfere with work activities. Until recently, frequently ineffective topical regimens or problematic surgical procedures have been the treatments of choice. Since 1996, intracutaneous injections of botulinum toxin have been used as a minimally invasive treatment for this condition with numerous studies documenting safety, efficacy, and extremely high levels of patient satisfaction. Botulinum toxin type A (Botox) was approved by the US Food and Drug Administration in 2004 for the treatment of axillary hyperhidrosis.

Axillary Hyperhidrosis: A 5-Year Review of Treatment Efficacy and Recurrence Rates Using a New Arthroscopic Shaver Technique

BACKGROUND

Axillary hyperhidrosis is a chronic condition characterized by excess axillary perspiration. This results in considerable patient morbidity, with no consistently efficacious medical or surgical treatment method described in the literature.

METHODS

All cases of axillary hyperhidrosis over a 5-year period were reviewed retrospectively. Data were gathered by a chart review and telephone interview. Inclusion criteria included primary hyperhidrosis, failed conservative therapy, no prior surgical therapy, surgical management using a new arthroscopic shaver technique (R.L.B.-S.), and 6 months of postoperative follow-up. The technique used was consistent between surgeons. Sweating severity was assessed using a subjective numerical rating scale ranging from 1 to 10. Patient demographics, symptom history, results, and complications were analyzed.

RESULTS

Average follow-up for 50 patients meeting the inclusion criteria was 28 months. The subjective severity scale demonstrated severity of 9.8 of 10 preoperatively and 2.3 of 10 postoperatively. Three patients (6 percent) reported mild recurrence of symptoms (4.6 of 10), which was not severe enough to seek further treatment. The average follow-up of those patients was 18.5 months. An overall subjective satisfaction of 96 percent was found, with a treatment success rate of 94 percent. Complications were minimal and self-limiting. The average time away from employment was 3.9 days and the average surgical operating room time was 46 minutes.

CONCLUSIONS

The authors' new arthroscopic shaver technique is efficacious, with no significant morbidity, a 96 percent satisfaction rate, a subjectively measured 75 percent reduction of sweat, and a recurrence rate of only 6 percent. For cases of primary hyperhidrosis affecting the axilla not amenable to conservative treatment, the authors recommend an arthroscopic shaver technique as the first-line treatment of choice.

Botulinum toxin: Clinical use

Since its development for the use of blepharospasm and strabismus more than 2.5 decades ago, botulinum neurotoxin (BoNT) has become a versatile drug in various fields of medicine. It is the standard of care in different disorders such as cervical dystonia, hemifacial spasm, focal spasticity, hyperhidrosis, ophthalmological and otolaryngeal disorders. It has also found widespread use in cosmetic applications. Many other indications are currently under investigation, including gastroenterologic and urologic indications, analgesic management and migraine. This paper is an extensive review of the spectrum of BoNT clinical applications.

Hyperhidrosis: a new and often early symptom in Fabry disease. International experience and data from the Fabry Outcome Survey

Hypohidrosis is a classic feature of Fabry disease; in contrast, hyperhidrosis has only been rarely described. The aim of the study is to characterise the baseline descriptive data on hyperhidrosis (frequency, age at onset, sex ratio and outcome with and without enzyme replacement therapy) in hemizygous male and heterozygous female patients with Fabry disease. We describe case histories of five patients with Fabry disease and hyperhidrosis seen at three different centres. We have also analysed a cohort of 21 paediatric patients in the UK and a large European cohort of patients enrolled in the Fabry Outcome Survey (FOS). Five patients (three female, two male) with hyperhidrosis were originally identified, although each had additional symptoms related to Fabry disease. The age at onset of hyperhidrosis was less than 18 years in four cases. In the cohort of 21 paediatric patients (12 female, nine male), one female had hyperhidrosis; the age at onset of this symptom was 11 years. In the FOS cohort, 66 of 714 patients with Fabry disease had hyperhidrosis (44 of 369 females, 11.9%; 22 of 345 males, 6.4%). The female predominance was observed in seven of nine countries from which data were analysed. Hyperhidrosis is an increasingly recognised feature of the Fabry disease phenotype. It is more prevalent in females than in males and often appears in childhood or adolescence. The efficacy of enzyme replacement therapy on this recently recognised symptom should be assessed.

Expanding use of botulinum toxin

Botulinum toxin type A (BTX-A) is best known to neurologists as a treatment for neuromuscular conditions such as dystonias and spasticity and has recently been publicized for the management of facial wrinkles. The property that makes botulinum toxin type A useful for these various conditions is the inhibition of acetylcholine release at the neuromuscular junction. Although botulinum toxin types A and B (BTX-A and BTX-B) continue to find new uses in neuromuscular conditions involving the somatic nervous system, it has also been recognized that the effects of these medications are not confined to cholinergic neurons at the neuromuscular junction. Acceptors for BTX-A and BTX-B are also found on autonomic nerve terminals, where they inhibit acetylcholine release at glands and smooth muscle. This observation led to trials of botulinum neurotoxins in various conditions involving autonomic innervation. The article reviews the emerging use of botulinum neurotoxins in these and selected other conditions, including sialorrhea, primary focal hyperhidrosis, pathological pain and primary headache disorders that may be of interest to neurologists and related specialists.