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Lowe N, Naumann M, Eadie N. Treatment of hyperhidrosis with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine (Baltimore) 2023; 102:e32764. [PMID: 37499084 PMCID: PMC10374185 DOI: 10.1097/md.0000000000032764] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Hyperhidrosis (chronic excessive sweating) may substantially affect an individual's emotional and social well-being. Therapies available before onabotulinumtoxinA were generally topical, with limited effectiveness, application-site skin reactions, and frequent, time-consuming treatments. Intradermal injection of onabotulinumtoxinA to treat sweat glands arose as a novel therapeutic approach. To develop this treatment, appropriate dosing needed to be established, and training on administration was required. Further, no previous scale existed to measure the effects of hyperhidrosis on patients' lives, leading Allergan to develop and validate the 4-point Hyperhidrosis Disease Severity Scale (HDSS), which measures the disease's impact on daily activities. The onabotulinumtoxinA clinical development program for hyperhidrosis included 2 double-blind, placebo-controlled pivotal trials, immunogenicity studies, long-term studies of safety and efficacy, and quality of life assessments. In Europe and North America, the primary efficacy measures were, respectively, axillary sweat production measured gravimetrically and HDSS improvement. Compared with placebo, onabotulinumtoxinA treatment significantly reduced axillary sweat production and axillary hyperhidrosis severity, as measured by a 2-point or greater reduction on the HDSS. The effects of onabotulinumtoxinA occurred rapidly, within 1 week after injection, and lasted ≥6 months. Treatment with onabotulinumtoxinA was associated with significant quality of life improvements based on Short Form-12 physical and mental component scores. The Hyperhidrosis Impact Questionnaire also indicated greater treatment satisfaction, reduced negative impact on aspects of daily life, and improved emotional well-being with onabotulinumtoxinA versus placebo. The clinical development program and subsequent clinical experience showed that onabotulinumtoxinA treatment for hyperhidrosis was well tolerated with no new safety signals, and led to greater disease awareness.
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Affiliation(s)
| | | | - Nina Eadie
- Former employee of Allergan plc, Irvine, CA, USA
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2
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Nationwide Cross-sectional Analysis of Endoscopic Thoracic Sympathectomy to Treat Hyperhidrosis Over 12 years in Brazil: Epidemiology, Costs, and Mortality. Ann Surg 2023; 277:e483-e487. [PMID: 34417365 DOI: 10.1097/sla.0000000000005178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze the number of endoscopic thoracic sympathectomies performed to treat hyperhidrosis in the Universal Public Health System of Brazil, the government reimbursements, and the in-hospital mortality rates. BACKGROUND Even though endoscopic thoracic sympathectomy has been widely performed for the definitive treatment of hyperhidrosis, no series reported mortality and there are no population-based studies evaluating its costs or its mortality rate. METHODS Data referring to endoscopic thoracic sympathectomy to treat hyperhidrosis between 2008 and 2019 were extracted from the database of the Brazilian Public Health System, which insures more than 160 million inhabitants. RESULTS Thirteen thousand two hundred one endoscopic thoracic sympathectomies to treat hyperhidrosis were performed from 2008 to 2019, with a rate of 68.44 procedures per 10 million inhabitants per year. There were 6 in-hospital deaths during the whole period, representing a mortality rate of 0.045%. The total expended throughout the years was U$ 6,767,825.14, with an average of U$ 512.68 per patient. CONCLUSIONS We observed a rate of 68.44 thoracoscopic sympathectomies for hyperhidrosis' treatment per 10 million inhabitants per year. The inhospital mortality rate was very low, 0.045%, though not nil. To our knowledge, no published series is larger than ours and we are the first authors to formally report deaths after endoscopic thoracic sympathectomies to treat hyperhidrosis. Moreover, there is no other population-based study addressing costs and mortality rates of every endoscopic thoracic sympathectomy for the treatment of any site of hyperhidrosis in a given period.
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Nasser S, Farshchian M, Kimyai-Asadi A, Potts GA. Techniques to Relieve Pain Associated With Botulinum Injections for Palmar and Plantar Hyperhidrosis. Dermatol Surg 2021; 47:1566-1571. [PMID: 34743126 DOI: 10.1097/dss.0000000000003182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Palmar and plantar hyperhidrosis (HH) is a common condition characterized by excessive sweating of the palms and soles. Botulinum neurotoxin (BTX) is a very effective and safe treatment. However, the associated intense injection pain is a major limiting factor deterring patients from selecting this treatment. OBJECTIVE The aim of this study was to review the numerous techniques used to minimize pain accompanying injections for palmoplantar HH. Additionally, the advantages and limitations of each modality will be discussed. MATERIALS AND METHODS The authors performed a comprehensive literature search in PubMed/MEDLINE, Embase, Cochrane Central, and Google Scholar on randomized controlled trials, cohort studies, and case series on techniques to relieve pain of BTX injections for treatment of palmar and plantar HH. RESULTS Current available techniques in reducing botulinum injection with merits and drawbacks are nerve blocks, Bier blocks, cryoanalgesia, needle-free anesthesia, topical anesthetics, and vibration anesthesia. CONCLUSION Topical anesthesia, ice, and vibration are the safest and most convenient noninvasive available methods to relieve pain associated with botulinum injection. Nerve blocks, Bier block, and needle-free anesthesia provide better anesthesia but are limited by the need for training and equipment.
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Affiliation(s)
- Sarah Nasser
- Wayne State University School of Medicine, Detroit, Michigan
| | - Mehdi Farshchian
- Department of Dermatology, Wayne State University, Dearborn, Michigan
| | | | - Geoffrey A Potts
- Department of Dermatology, Wayne State University, Dearborn, Michigan
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Wade R, Rice S, Llewellyn A, Moloney E, Jones-Diette J, Stoniute J, Wright K, Layton AM, Levell NJ, Stansby G, Craig D, Woolacott N. Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis. Health Technol Assess 2019; 21:1-280. [PMID: 29271741 DOI: 10.3310/hta21800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable. OBJECTIVE To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care. METHODS A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only. RESULTS AND CONCLUSIONS Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life. LIMITATIONS The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla. FUTURE WORK Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses. STUDY REGISTRATION This study is registered as PROSPERO CRD42015027803. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Ros Wade
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Rice
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Eoin Moloney
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Julija Stoniute
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Nick J Levell
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Gerard Stansby
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, UK
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Dias L, Marçal L, Rodrigues M, Alves TCA, Pondé MP. Eficácia da Toxina Botulínica no Tratamento da Hiperidrose. ACTA ACUST UNITED AC 2019. [DOI: 10.34024/rnc.2001.v9.8911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A hiperidrose é caracterizada por um suor excessivo e sem controle decorrente de uma hiperatividade simpática. Essa afecção pode causar sérios problemas sociais, psicológicos e ocupacionais. Os tratamentos convencionais como o uso de antiperspirantes, iontoforese ou a simpatectomia não são eficazes em casos mais severos, ou então são muito arriscados. A toxina botulínica tipo A surgiu como um tratamento seguro e eficaz da hiperidrose, ao bloquear a liberação da acetilcolina nas membranas pré-sinápticas. Este estudo tem como objetivo revisar criticamente a literatura sobre o tema. Os resultados apresentados foram obtidos de seis trabalhos realizados com pacientes que comprovadamente tinham hiperidrose. A redução percentual da sudorese foi de 86% no estudo realizado por Heckmann et al. (2001), 69,1% no de Kinkelin et al., 63,7% no estudo de Heckmann et al. (1999) e de 69% nos de Solomon e Itayman. Poucos efeitos colaterais foram relatados, sendo eles dor e ardência durante as injeções e fraquezas transitórias dos músculos do polegar e da testa. O tratamento da hiperidrose palmoplantar, axilar e frontal com a toxina botulínica tem se mostrado eficaz e seguro, reabilitando o indivíduo às suas atividades no mesmo dia. A única desvantagem desse tratamento é o seu alto custo, que limita significativamente o seu uso.
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Abstract
Background Jet injection can be defined as a needle-free drug delivery method in which a high-speed stream of fluid impacts the skin and delivers a drug. Despite 75 years of existence, it never reached its full potential as a strategic tool to deliver medications through the skin. Objective The aim of this review was to evaluate and summarize the evolution of jet injection intradermal drug delivery method including technological advancements and new indications for use. Methods A review of the literature was performed with no limits placed on publication date. Results Needleless injectors not only reduce pain during drug delivery but also confine the drug more evenly in the dermis. Understanding skin properties of the injection site is a key factor to obtain optimal results as well as setting the right parameters of the jet injector. Until the advent of disposable jet injectors/cartridges, autoclaving of the injector remains the only reliable method to eliminate the risk of infection. Needle-free intradermal injection using corticosteroids and/or local anesthetics is well documented with promising indications being developed. Limitations Limitations of the review include low-quality evidence, small sample sizes, varying treatment parameters, and publication bias. Conclusion New developments may help reconsider the use of jet injection technology. Future studies should focus on measurable optimized parameters to insure a safe and effective outcome.
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Affiliation(s)
- Daniel Barolet
- RoseLab Skin Optics Research Laboratory, Laval, QC, Canada.,MUHC Dermatology Service, Department of Medicine, McGill University, Montreal, QC, Canada
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Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies. J Am Acad Dermatol 2017; 76:1027-1042. [PMID: 28522039 DOI: 10.1016/j.jaad.2016.11.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022]
Abstract
The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.
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Affiliation(s)
| | - Seth L Matarasso
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.
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Dutta SR, Passi D, Singh M, Singh P, Sharma S, Sharma A. Botulinum toxin the poison that heals: A brief review. Natl J Maxillofac Surg 2016; 7:10-16. [PMID: 28163472 PMCID: PMC5242063 DOI: 10.4103/0975-5950.196133] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Botulinum neurotoxins, causative agents of botulism in humans, are produced by Clostridium botulinum, an anaerobic spore-former Gram-positive bacillus. Botulinum neurotoxin poses a major bioweapon threat because of its extreme potency and lethality; its ease of production, transport, and misuse; and the need for prolonged intensive care among affected persons. This paper aims at discussing botulinum neurotoxin, its structure, mechanism of action, pharmacology, its serotypes and the reasons for wide use of type A, the various indications and contraindications of the use of botulinum neurotoxin and finally the precautions taken when botulinum neurotoxin is used as a treatment approach. We have searched relevant articles on this subject in various medical databases including Google Scholar, PubMed Central, ScienceDirect, Wiley Online Library, Scopus, and Copernicus. The search resulted in more than 2669 articles, out of which a total of 187 were reviewed. However, the review has been further constricted into only 54 articles as has been presented in this manuscript keeping in mind the page limitation and the limitation to the number of references. A single gram of crystalline toxin, evenly dispersed and inhaled, can kill more than one million people. The basis of the phenomenal potency of botulinum toxin (BT) is enzymatic; the toxin is a zinc proteinase that cleaves neuronal vesicle-associated proteins responsible for acetylcholine release into the neuromuscular junction. A fascinating aspect of BT research in recent years has been the development of the most potent toxin into a molecule of significant therapeutic utility. It is the first biological toxin which is licensed for the treatment of human diseases. The present review focuses on both warfare potential as well as medical uses of botulinum neurotoxin.
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Affiliation(s)
- Shubha Ranjan Dutta
- Department of Oral and Maxillofacial Surgery, MB Kedia Dental College, Birgunj, Nepal
| | - Deepak Passi
- Department of Oral and Maxillofacial Surgery, ESIC Dental College and Hospital, New Delhi, India
| | - Mahinder Singh
- Department of Oral and Maxillofacial Surgery, Uttaranchal Dental and Medical Research Institute, Dehradun, Uttarakhand, India
| | - Purnima Singh
- Department of Physiology, MB Kedia Dental College, Birgunj, Nepal
| | - Sarang Sharma
- Department of Conservative Dentistry and Endodontics, ESIC Dental College and Hospital, New Delhi, India
| | - Abhimanyu Sharma
- Department of Conservative Dentistry and Endodontics, ESIC Dental College and Hospital, New Delhi, India
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Lecouflet M, Leux C, Fenot M, Célerier P, Maillard H. Duration of efficacy increases with the repetition of botulinum toxin A injections in primary palmar hyperhidrosis: A study of 28 patients. J Am Acad Dermatol 2014; 70:1083-7. [DOI: 10.1016/j.jaad.2013.12.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/19/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
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Olea E, Fondarella A, Sánchez C, Iriarte I, Almeida MV, Martínez de Salinas A. [Ultrasound-guided peripheral nerve block at wrist level for the treatment of idiopathic palmar hyperhidrosis with botulinum toxin]. ACTA ACUST UNITED AC 2013; 60:571-5. [PMID: 24210213 DOI: 10.1016/j.redar.2013.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 08/01/2013] [Accepted: 08/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Evaluation of pain and degree of satisfaction in patients undergoing ultrasound-assisted peripheral regional block for the treatment of idiopathic palmar hyperhidrosis with botulinum toxin. PATIENTS AND METHODS A descriptive, observational study of patients with palmar hyperhidrosis treated with botulinum toxin A, who underwent ultrasound-guided peripheral regional block of the median and ulnar nerves with 3 ml of mepivacaine 1% in each one. The radial nerve block was injected in the anatomical snuffbox. After establishing blocking, the dermatologist performed a mapping and injected around 100 IU of botulinum toxin across the whole palm. The pain experienced during the injection of botulinum toxin was evaluated by verbal numerical scale (from 0 to 10), along with the degree of satisfaction with the anesthetic technique, and the post-anesthetic complications. RESULTS A total of 40 patients were enrolled in the study, 11 men and 29 women with no significant differences. The pain intensity assessed with verbal numerical scale was 1.03 (standard deviation of 1.37). No patients had a value greater than 5. The degree of patient satisfaction with the anesthetic technique was very good for 85% of the patients, and good for 7.5%. There were no complications related to type of anesthesia. CONCLUSIONS The ultrasound-assisted peripheral regional block could be a simple, effective and safe technique for patients undergoing palmar injection of botulinum toxin. Pain intensity was very low, and it provided a very good level of satisfaction in most patients.
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Affiliation(s)
- E Olea
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Álava, Vitoria-Gasteiz, Álava, España.
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Hanke CW, Moy RL, Roenigk RK, Roenigk HH, Spencer JM, Tierney EP, Bartus CL, Bernstein RM, Brown MD, Busso M, Carruthers A, Carruthers J, Ibrahimi OA, Kauvar ANB, Kent KM, Krueger N, Landau M, Leonard AL, Mandy SH, Rohrer TE, Sadick NS, Wiest LG. Current status of surgery in dermatology. J Am Acad Dermatol 2013; 69:972-1001. [PMID: 24099730 DOI: 10.1016/j.jaad.2013.04.067] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 02/08/2023]
Abstract
An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.
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Economic evaluation of botulinum toxin versus thoracic sympathectomy for palmar hyperhidrosis: data from a real-world scenario. Dermatol Ther (Heidelb) 2013; 3:63-72. [PMID: 23888256 PMCID: PMC3680634 DOI: 10.1007/s13555-013-0025-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Local botulinum toxin injections and endoscopic thoracic sympathectomy (ETS) have shown clinical effectiveness for the treatment of palmar hyperhidrosis in several studies. Although both strategies cause considerable costs for health-care systems, at the moment there are no studies examining directly their cost-effectiveness performance. The aim of the study was to assess the incremental cost-effectiveness of botulinum toxin when compared with ETS for palmar hyperhidrosis. MATERIALS AND METHODS Costs, effectiveness, and incremental cost-effectiveness ratio (ICER) were calculated. Costs were assessed from a Spanish National Health System perspective in a historical cohort of patients with palmar hyperhidrosis attending a tertiary referral hospital. Effectiveness was evaluated by using the Hyperhidrosis Disease Severity Scale (HDSS). A responder was defined as a patient who reported at least a two-grade improvement on the HDSS scale with respect to the baseline value. The horizon of time was 1 year. RESULTS Effectiveness was greater for ETS (n = 128) when compared with botulinum toxin (n = 100) for the treatment of palmar hyperhidrosis (92% vs. 68%; odds ratio (OR) = 6.22 [2.80, 13.80]; absolute risk ratio (ARR) = -0.24 [-0.45, -0.14]; number-needed-to-treat (NNT) = -4 [-2, -11]). Botulinum toxin had an ICER of 125 € when compared with ETS during the first year of treatment. CONCLUSIONS In this retrospective real-world observational sample of patients with palmar hyperhidrosis, treatment with ETS appears to be more effective and less costly when compared with botulinum toxin during the first year of treatment. Analyses such as this give decision makers the tools to choose a better treatment option which is both highly effective and yet has a low cost.
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Campanati A, Giuliodori K, Giuliano A, Martina E, Ganzetti G, Marconi B, Chiarici A, Offidani A. Treatment of palmar hyperhidrosis with botulinum toxin type A: results of a pilot study based on a novel injective approach. Arch Dermatol Res 2013; 305:691-7. [DOI: 10.1007/s00403-013-1380-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 05/30/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
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Öncel M. Bilateral thoracoscopic sympathectomy for primary hyperhydrosis: a review of 335 cases. Cardiovasc J Afr 2013; 24:137-40. [PMID: 24217046 PMCID: PMC3734871 DOI: 10.5830/cvja-2013-007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 01/24/2013] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The goal of this retrospective study was to evaluate the outcomes of bilateral video-assisted thoracoscopic sympathectomy for primary hyperhydrosis. METHODS Between January 2007 and December 2011, a total of 335 patients (192 male, 143 female, mean age 28.3 years) who underwent bilateral thoracoscopic sympathectomy for primary hyperhydrosis were reviewed retrospectively. RESULTS Hyperhydrosis occurred in the palmar and axillary region in 175 (52.23%) patients, in only the palmar region in 52 (15.52%), in the craniofacial region in 44 (13.13%), in only the axillary region in 42 (12.53%), and in the palmar and pedal regions in 22 (6.56%) patients. Bilateral thoracoscopic sympathectomy was performed in all patients. The mean follow-up period was 24 (6-48) months. The initial cure rate was 95% and the initial satisfaction rate was 93%. There was no mortality in this study. The complication rate was 15.82% in 53 patients. CONCLUSION Video-assisted thoracoscopic sympathectomy for the treatment of primary hyperhydrosis was effective, with low rates of morbidity and mortality. Despite the appearance of postoperative complications, such as compensatory sweating, patient satisfaction with the procedure was high and their quality of life improved.
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Affiliation(s)
- Murat Öncel
- Department of Thoracic Surgery, Selcuklu Medicine Faculty, Selcuk University, Konya, Turkey
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Chung IC, McGeorge BCL. Botulinum toxin type A should be PBS listed for treatment of palmar hyperhidrosis. Med J Aust 2012; 197:445. [DOI: 10.5694/mja12.11150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Bruce C L McGeorge
- Royal Darwin Hospital, Darwin, NT
- Faculty of Health Sciences, Flinders University, Adelaide, SA
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18
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Botulinum toxin therapy: its use for neurological disorders of the autonomic nervous system. J Neurol 2012; 260:701-13. [DOI: 10.1007/s00415-012-6615-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 07/06/2012] [Accepted: 07/09/2012] [Indexed: 11/26/2022]
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Abstract
Hyperhidrosis is a disorder of excessive sweating beyond what is expected for thermoregulatory needs and environmental conditions. Primary hyperhidrosis has an estimated prevalence of nearly 3% and is associated with significant medical and psychosocial consequences. Most cases of hyperhidrosis involve areas of high eccrine density, particularly the axillae, palms, and soles, and less often the craniofacial area. Multiple therapies are available for the treatment of hyperhidrosis. Options include topical medications (most commonly aluminum chloride), iontophoresis, botulinum toxin injections, systemic medications (including glycopyrrolate and clonidine), and surgery (most commonly endoscopic thoracic sympathectomy [ETS]). The purpose of this article is to comprehensively review the literature on the subject, with a focus on new and emerging treatment options. Updated therapeutic algorithms are proposed for each commonly affected anatomic site, with practical procedural guidelines. For axillary and palmoplantar hyperhidrosis, topical treatment is recommended as first-line treatment. For axillary hyperhidrosis, botulinum toxin injections are recommended as second-line treatment, oral medications as third-line treatment, local surgery as fourth-line treatment, and ETS as fifth-line treatment. For palmar and plantar hyperhidrosis, we consider a trial of oral medications (glycopyrrolate 1-2 mg once or twice daily preferred to clonidine 0.1 mg twice daily) as second-line therapy due to the low cost, convenience, and emerging literature supporting their excellent safety and reasonable efficacy. Iontophoresis is considered third-line therapy for palmoplantar hyperhidrosis; efficacy is high although so are the initial levels of cost and inconvenience. Botulinum toxin injections are considered fourth-line treatment for palmoplantar hyperhidrosis; efficacy is high though the treatment remains expensive, must be repeated every 3-6 months, and is associated with pain and/or anesthesia-related complications. ETS is a fifth-line option for palmar hyperhidrosis but is not recommended for plantar hyperhidrosis due to anatomic risks. For craniofacial hyperhidrosis, oral medications (either glycopyrrolate or clonidine) are considered first-line therapy. Topical medications or botulinum toxin injections may be useful in some cases and ETS is an option for severe craniofacial hyperhidrosis.
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Abstract
Botulinum toxin, one of the most poisonous biological substances known, is a neurotoxin produced by the bacterium Clostridium botulinum. C. botulinum elaborates eight antigenically distinguishable exotoxins (A, B, C1, C2, D, E, F and G). All serotypes interfere with neural transmission by blocking the release of acetylcholine, the principal neurotransmitter at the neuromuscular junction, causing muscle paralysis. The weakness induced by injection with botulinum toxin A usually lasts about three months. Botulinum toxins now play a very significant role in the management of a wide variety of medical conditions, especially strabismus and focal dystonias, hemifacial spasm, and various spastic movement disorders, headaches, hypersalivation, hyperhidrosis, and some chronic conditions that respond only partially to medical treatment. The list of possible new indications is rapidly expanding. The cosmetological applications include correction of lines, creases and wrinkling all over the face, chin, neck, and chest to dermatological applications such as hyperhidrosis. Injections with botulinum toxin are generally well tolerated and side effects are few. A precise knowledge and understanding of the functional anatomy of the mimetic muscles is absolutely necessary to correctly use botulinum toxins in clinical practice.
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Affiliation(s)
- P K Nigam
- Department of Dermatology and STD, Pt. J.N.M. Medical College and Assoc. Dr. B.R.A.M. Hospital, Raipur - 492 001, India.
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Ambrogi V, Campione E, Mineo D, Paternò EJ, Pompeo E, Mineo TC. Bilateral thoracoscopic T2 to T3 sympathectomy versus botulinum injection in palmar hyperhidrosis. Ann Thorac Surg 2009; 88:238-45. [PMID: 19559233 DOI: 10.1016/j.athoracsur.2009.04.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 03/31/2009] [Accepted: 04/01/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bilateral T2 to T3 thoracoscopic sympathectomy and injection of botulinum toxin-A are presently the most effective modalities in the treatment of primary palmar hyperhidrosis. In this study we evaluated comparative merits of the two therapies. METHODS Patients suffering primary palmar hyperhidrosis were treated by either bilateral T2 to T3 thoracoscopic sympathectomy (n = 68) or by injection of botulinum toxin-A (n = 86). The groups were homogeneous for relevant demographic, physiologic, and clinical data. Quantification of sweat production was performed by Minor's iodine starch and glove tests. Subjective changes were assessed by quality of life questionnaires (Hyperhidrosis, Dermatology Life Quality Index, Short Form-36, Nottingham's Health Profile) and patient's satisfaction self-assessment. A cost comparison between groups was also carried out. RESULTS No operative mortality or major morbidity was recorded in either group. Minor's test showed a more significant reduction in the surgical group: +94% versus +63% at 6 months and +94% versus +30% at 12 months. Compensatory sweating was significantly greater and long-lasting in the surgical group. All subjective tests improved rapidly and significantly in both groups. After 6 months, results mildly worsened in the surgical group and more significantly in the botulinum group. Patient's satisfaction was initially greater in the botulinum group (p = 0.03), but after 6 months it significantly reversed (p = 0.04). Surgical treatment cost approximately as much as four botulinum treatments. CONCLUSIONS Thoracoscopic sympathectomy is superior to botulinum toxin-A injection. The greater initial costs and discomfort are offset by a greater reduction in compensatory sweating.
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Affiliation(s)
- Vincenzo Ambrogi
- Division of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
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Abstract
Primary focal hyperhidrosis is a disorder of idiopathic excessive sweating that typically affects the axillae, palms, soles, and face. The disorder, which affects up to 2.8% of the US population, is associated with considerable physical, psychosocial, and occupational impairments. Current therapeutic strategies include topical aluminum salts, tap-water iontophoresis, oral anticholinergic agents, local surgical approaches, and sympathectomies. These treatments, however, have been limited by a relatively high incidence of adverse effects and complications. Non-surgical treatment complications are typically transient, whereas those of surgical therapies may be permanent and significant. Recently, considerable evidence suggests that botulinum toxin type A (BTX-A) injections into hyperhidrotic areas can considerably reduce focal sweating in multiple areas without major adverse effects. BTX-A has therefore shown promise as a potential replacement for more invasive treatments after topical aluminum salts have failed. This article reviews the epidemiology, diagnosis, and management of primary focal hyperhidrosis, with an emphasis on recent research evidence supporting the use of BTX-A injections for this indication.
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Affiliation(s)
- Alexander Grunfeld
- Faculty of Medicine, University of Toronto, Women's College Hospital, Toronto, Ontario, Canada
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Yamashita N, Shimizu H, Kawada M, Yanagishita T, Watanabe D, Tamada Y, Matsumoto Y. Local injection of botulinum toxin A for palmar hyperhidrosis: usefulness and efficacy in relation to severity. J Dermatol 2008; 35:325-9. [PMID: 18578708 DOI: 10.1111/j.1346-8138.2008.00478.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Noriko Yamashita
- Department of Dermatology, Aichi Medical University School of Medicine, Aichi, Japan.
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Laing TA, Laing ME, O'Sullivan ST. Botulinum toxin for treatment of glandular hypersecretory disorders. J Plast Reconstr Aesthet Surg 2008; 61:1024-8. [PMID: 18619934 DOI: 10.1016/j.bjps.2008.03.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 02/23/2008] [Accepted: 03/06/2008] [Indexed: 11/19/2022]
Abstract
SUMMARY The use of botulinum toxin to treat disorders of the salivary glands is increasing in popularity in recent years. Recent reports of the use of botulinum toxin in glandular hypersecretion suggest overall favourable results with minimal side-effects. However, few randomised clinical trials means that data are limited with respect to candidate suitability, treatment dosages, frequency and duration of treatment. We report a selection of such cases from our own department managed with botulinum toxin and review the current data on use of the toxin to treat salivary gland disorders such as Frey's syndrome, excessive salivation (sialorrhoea), focal and general hyperhidrosis, excessive lacrimation and chronic rhinitis.
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Affiliation(s)
- T A Laing
- Department of Plastic and Reconstructive Surgery, Cork University Hospital, Cork, Ireland
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Davarian S, Kalantari KK, Rezasoltani A, Rahimi A. Effect and persistency of botulinum toxin iontophoresis in the treatment of palmar hyperhidrosis. Australas J Dermatol 2008; 49:75-9. [DOI: 10.1111/j.1440-0960.2008.00441.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reisfeld R. Sympathectomy for hyperhidrosis: should we place the clamps at T2–T3 or T3–T4? Clin Auton Res 2006; 16:384-9. [PMID: 17083007 DOI: 10.1007/s10286-006-0374-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Accepted: 09/18/2006] [Indexed: 10/24/2022]
Abstract
Endoscopic thoracic sympathectomy is routinely used to treat severe hyperhidrosis. It is usually performed at the T2-T3 level of the nerve, but may produce less severe compensatory hidrosis if performed at a lower level. This study evaluates the outcome of 1,274 patients who underwent endoscopic thoracic sympathectomy for plamar, plantar, axillary or facial hyperhidrosis/blushing. Half of the patients were clamped at the T2-T3 level and half were clamped at the T3-T4 level. Postsurgical symptoms and side effects were assessed by interview. All of patients with palmar hyperhidrosis were cured or improved. Patients with plantar and axillary hyperhidrosis were more likely to be improved at T3-T4 level clamping. Patients with facial hyperhidrosis were more likely to be cured at T2-T3 level, but did show improvement at the T3-T4 level. Overall satisfaction was higher in the T3-T4 group. Some degree of mild compensatory sweating occurred in all patients. However, severe compensatory sweating was more common in the T2-T3 group. Around 2% of patients requested a reversal of their surgery. Endoscopic thoracic sympathectomy is a safe and effective treatment for hyperhidrosis. Clamping at the T3-T4 level has a more successful outcome. In particular, it appears to reduce the incidence of severe compensatory hidrosis.
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Truong DD, Jost WH. Botulinum toxin: Clinical use. Parkinsonism Relat Disord 2006; 12:331-55. [PMID: 16870487 DOI: 10.1016/j.parkreldis.2006.06.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 06/21/2006] [Accepted: 06/21/2006] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Daniel D Truong
- The Parkinson's and Movement Disorder Institute, 9940 Talbert Avenue, Fountain Valley, CA 92708, USA.
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Baumann L, Slezinger A, Halem M, Vujevich J, Mallin K, Charles C, Martin LK, Black L, Bryde J. Double-Blind, Randomized, Placebo-Controlled Pilot Study of the Safety and Efficacy of Myobloc (Botulinum Toxin Type B) for the Treatment of Palmar Hyperhidrosis. Dermatol Surg 2006; 31:263-70. [PMID: 15841624 DOI: 10.1111/j.1524-4725.2005.31071] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Palmar hyperhidrosis is a problem of unknown etiology that affects patients both socially and professionally. Botulinum toxin type B (Myobloc), approved by the Food and Drug Administration for use in the treatment of cervical dystonia in the United States in December 2000, has subsequently been used effectively in an off-label indication to treat hyperhidrosis. There are sparse data, however, in the literature evaluating the safety and efficacy of BTX-B for the treatment of palmar hyperhidrosis. OBJECTIVE We evaluated the safety and efficacy of Myobloc in the treatment of bilateral palmar hyperhidrosis. This was a double-blind, randomized, placebo-controlled study to report on the safety and efficacy of Myobloc. METHODS Twenty participants (10 men, 10 women) diagnosed with palmar hyperhidrosis were injected with either Myobloc (5,000 U per palm) or a 1.0 mL vehicle (100 mM NaCl, 10 mM succinate, and 0.5 mg/mL human albumin) into bilateral palms (15 Myobloc, 5 placebo). The participants were followed until sweating returned to baseline levels. The main outcome measures were safety, efficacy versus placebo, and duration of effect. RESULTS A significant difference was found in treatment response at day 30, as determined by participant assessments, between 15 participants injected with Myobloc and 3 participants injected with placebo. The duration of action, calculated in the 17 participants who received Myobloc injections and completed the study, ranged from 2.3 to 4.9 months, with a mean duration of 3.8 months. The single most reported adverse event was dry mouth or throat, which was reported by 18 of 20 participants. The adverse event profile also included indigestion or heartburn (60%), excessively dry hands (60%), muscle weakness (60%), and decreased grip strength (50%). CONCLUSION Myobloc proved to be efficacious for the treatment of palmar hyperhidrosis. Myobloc had a rapid onset, with most participants responding within 1 week. The duration of action ranged from 2.3 to 4.9 months, with a mean of 3.8 months. The adverse event profile included dry mouth, indigestion or heartburn, excessively dry hands, muscle weakness, and decreased grip strength.
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Affiliation(s)
- Leslie Baumann
- Department of Dermatology and Cutaneous Surgery/Division of Cosmetic Dermatology, University of Miami, Miami, Florida, USA.
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Bhidayasiri R, Truong DD. Expanding use of botulinum toxin. J Neurol Sci 2005; 235:1-9. [PMID: 15990116 DOI: 10.1016/j.jns.2005.04.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Revised: 04/14/2005] [Accepted: 04/18/2005] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Roongroj Bhidayasiri
- Department of Neurology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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Pérez-Bernal AM, Avalos-Peralta P, Moreno-Ramírez D, Camacho F. Treatment of palmar hyperhidrosis with botulinum toxin type A: 44 months of experience. J Cosmet Dermatol 2005; 4:163-6. [PMID: 17129260 DOI: 10.1111/j.1473-2165.2005.00304.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Schiener R, Gottlöber P, Müller B, Williams S, Pillekamp H, Peter RU, Kerscher M. PUVA-gel vs. PUVA-bath therapy for severe recalcitrant palmoplantar dermatoses. A randomized, single-blinded prospective study. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2005; 21:62-7. [PMID: 15752122 DOI: 10.1111/j.1600-0781.2005.00134.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE In order to avoid unwanted effects of systemic psoralen and ultraviolet A (PUVA) therapy, various topical PUVA treatment modalities have been developed and are being increasingly used. However, up to now very few controlled studies comparing the therapeutic efficacy of different topical photochemotherapy modalities are available. Thus, the aim of our study was to compare the clinical efficacy of conventional PUVA-bath therapy to topical PUVA-gel therapy in patients with recalcitrant dermatoses of the palms and soles. METHODS Twenty patients with severe palmoplantar dermatoses or localized psoriatic plaques were enrolled in our observer-blinded, randomized half-sided study. The treatment modalities compared were: (i) aqueous 8-methoxypsoralen (8-MOP)-containing gel plus broadband UVA irradiation (PUVA-gel therapy) and (ii) 8-MOP bath of the hands and/or feet plus broadband UVA (PUVA-bath therapy). RESULTS On the body half, which was randomized to PUVA-gel therapy, the median Area and Severity Index for palmoplantar dermatoses (ASIppd) decreased from 28 (range 6-56) to 1.5 (range 1-37, P = 0.00) after a median 33 (13-49) irradiations compared with a reduction from 26.5 (range 6-52.5) to 1.5 (range 0-38, P = 0.00) for PUVA-bath therapy. Both improvements of ASIppd scores were found to be statistically significant, with no significant difference between PUVA-gel and PUVA-bath therapy. Severe phototoxic reactions such as strong erythema, blistering and/or pain were not observed in any patient. CONCLUSION PUVA-gel therapy seems to be an effective therapeutic alternative to conventional PUVA-bath therapy in treating localized dermatoses of the palms and soles. The advantage of PUVA-gel therapy is reduced organizational efforts and expenses.
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Affiliation(s)
- Ralf Schiener
- Department of Dermatology, Venerology and Allergology, Federal Armed Forces Hospital, Ulm, Germany
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Sutcliffe RP, Sandiford NA, Khawaja HT. From frown lines to fissures: Therapeutic uses for botulinum toxin. Int J Surg 2005; 3:141-6. [PMID: 17462275 DOI: 10.1016/j.ijsu.2005.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2005] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Since the pharmacological mode of action of botulinum toxin (BTX) has been elucidated, its therapeutic potential has been increasingly recognised. The aims of this review were to summarize our current understanding of the pharmacological action of this agent and to review its therapeutic uses. METHODS An electronic literature search with Medline (January 1965 to December 2004) was carried out to identify articles related to the pharmacological mode of action and clinical uses for botulinum toxin using the keyword "botulinum toxin". RESULTS AND CONCLUSION Botulinum toxin A is emerging as a valuable clinical tool, both for diagnostic and therapeutic purposes in a wide variety of disorders, and is already the treatment of choice for selected conditions. Better understanding of its modes of action may identify alternative targets for pharmacological intervention, and may allow development of longer acting drugs with lower immunogenicity. Therapeutic uses of BTX-A must be assessed systematically in prospective studies, and the clinical role of other subtypes requires evaluation.
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Affiliation(s)
- R P Sutcliffe
- Department of Surgery, Queen Mary's Hospital, Sidcup, Kent, UK.
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Abstract
We report two patients with severe palmar hyperhidrosis who responded to BOTOX delivered not by injection, the usual method of delivery, but by iontophoresis. The Botulinum molecule has been considered too large for delivery into the skin this way. However, other large peptides, both non-ionic and cationic, have been delivered successfully by this method, so we suspected that BOTOX could in fact be iontophoresed. Our saline-controlled treatment of these two patients with a small iontophoresis unit (Iomed Phoresor II) allowed small volumes of standard BOTOX dilutions to be used, and demonstrates that iontophoresis can indeed deliver BOTOX successfully. This has important therapeutic potential for the large number of patients with focal hyperhidrosis. They may be spared painful injections, and in more severe cases, invasive surgery.
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Affiliation(s)
- G M Kavanagh
- University Department of Dermatology, The Royal Infirmary of Edinburgh, Lauriston Building, Edinburgh EH3 9YW, Scotland, UK.
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Campanati A, Lagalla G, Penna L, Gesuita R, Offidani A. Local neural block at the wrist for treatment of palmar hyperhidrosis with botulinum toxin: Technical improvements. J Am Acad Dermatol 2004; 51:345-8. [PMID: 15337974 DOI: 10.1016/j.jaad.2003.09.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Wrist blockage of median and ulnar nerves before treatment of palmar hyperhidrosis with botulinum toxin (BTX-A) reduces discomfort and improves accuracy of BTX-A injections, but can be associated with mechanical/chemical injury. OBJECTIVES We sought to compare locoregional anesthesia of median and ulnar nerves using conventional 25-G x 0.50 x 13 mm gauge needle with short 30-G x 0.40 x 6 mm gauge needle. METHODS In all, 37 patients with idiopathic, recalcitrant palmar hyperhidrosis were treated with BTX-A after median and ulnar nerve blockage. In 18 patients, a conventional needle was used to achieve nerve blockage and in 19 the short needle was used. The 2 groups of patients were compared for analgesic effects and lag phase. RESULTS No differences were found between groups for lag phase (P=.26) and discomfort of subsequent BTX-A treatment (P=1.0). CONCLUSION The use of a short-gauge needle to block median and ulnar nerves is a suitable method to anesthetize the palm before treatment with BTX-A.
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Abstract
Focal idiopathic and episodic eccrine sweating of the axillae, palms, soles, and face troubles afflicted individuals with a social curse that can only be imagined by those whose hands or underarms dampen only occasionally. Although there is no accurate incidence in the epidemiology literature, it seems that about half of the patients who have presented to the author with this condition have at least one first-degree relative similarly affected. Social stigma, lack of understanding on the part of medical providers as to the cause and nature of the problem, and lack of effective therapy keeps most of these patients from seeking medical care. This article investigates the treatment of hyperhidrosis with botulinum toxin.
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Affiliation(s)
- Richard G Glogau
- Department of Dermatology, University of California at San Francisco, 350 Parnassus Avenue, Suite 400, San Francisco, CA 94117-3685, USA.
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Cordivari C, Misra VP, Catania S, Lees AJ. New therapeutic indications for botulinum toxins. Mov Disord 2004; 19 Suppl 8:S157-61. [PMID: 15027069 DOI: 10.1002/mds.20071] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The efficacy of botulinum toxin (BTX) without systemic effects has led to the rapid development of applications in neuromuscular disorders, hyperactivity of sudomotor cholinergic-mediated glandular function, and pain syndromes. The successful use of BTX in conditions with muscle overactivity, such as dystonia and spasticity, has been established and new areas in the field of movement disorders such as tics, tremor, myoclonic jerks, and stuttering has been explored with satisfactory results. Strategies to temporarily inactivate muscle function after orthopaedic or neurosurgery have also been developed. BTX treatment of hyperhidrosis was followed by its application in other hypersecretory conditions (hyperlacrimation and nasal hypersecretion) and in excessive drooling. Studies are in progress, aimed at optimising the technique and protocol of administration. Other applications for BTX have been proposed in gastroenterological and urogenital practice; it appears to be effective in replacing standard surgical procedures. Trials of BTX in painful conditions are ongoing mainly on refractory tension headache, migraine, and backache as well as dystonia-complex regional pain syndrome and myofascial pain with promising results. Recently, the fastest growing use for BTX toxin has been in the cosmetic applications. Clearly, the indications for the use of BTX are expanding, but further clinical trials will be needed in many different areas.
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Affiliation(s)
- Carla Cordivari
- Department of Clinical Neurophysiology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, United Kingdom
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Abstract
Botulinum neurotoxin serotype A (BoNT/A) has revolutionised the treatment of a variety of autonomic hypersecretory disorders. Several open and controlled studies indicate that BoNT/A is a safe and effective treatment for focal hyperhidrosis of the axillae and palms, for gustatory sweating, and for some other rare conditions associated with focal hyperhidrosis. There is class I evidence for the efficacy of botulinum toxin in axillary hyperhidrosis and class II evidence for palmar hyperhidrosis and gustatory sweating. BoNT/A has the potential to replace current invasive and surgical techniques and should at least be considered as a viable alternative. The results of pilot studies to treat sialorrhea are encouraging. However, the optimal dose, best mode of application, side effects, and duration of BoNT/A action in this condition remain uncertain. We need further formal clinical trials to evaluate risks and benefits of BoNT/A for palliative treatment in of sialorrhea in Parkinson's disease and in bulbar amyotrophic lateral sclerosis. Based on the few reports published, BoNT/A injections into the lacrimal gland for hyperlacrimation may be an elegant method to treat this sometimes disabling condition. Again, larger studies are needed to evaluate the risks and long-term benefits of this treatment option.
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Affiliation(s)
- Markus Naumann
- Department of Neurology, University of Würzburg, Würzburg, Germany.
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39
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Connolly M, de Berker D. Management of primary hyperhidrosis: a summary of the different treatment modalities. Am J Clin Dermatol 2004; 4:681-97. [PMID: 14507230 DOI: 10.2165/00128071-200304100-00003] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Hyperhidrosis is a common and distressing condition involving increased production of sweat. A variety of treatment modalities are used to try to control or reduce sweating. Sweat is secreted by eccrine glands innervated by cholinergic fibers from the sympathetic nervous system. Primary hyperhidrosis most commonly affects palms, axillae and soles. Secondary hyperhidrosis is caused by an underlying condition, and treatment involves the removal or control of this condition. The treatment options for primary hyperhidrosis involve a range of topical or systemic medications, psychotherapy and surgical or non-surgical invasive techniques. Topical antiperspirants are quick and easy to apply but they can cause skin irritation and have a short half life. Systemic medications, in particular anticholinergics, reduce sweating but the dose required to control sweating can cause significant adverse effects, thus, limiting the medications' effectiveness. Iontophoresis is a simple and well tolerated method for the treatment of hyperhidrosis without long-term adverse effects; however, long-term maintenance treatments are required to keep patients symptom free. Botulinum toxin A has emerged as a treatment for hyperhidrosis over the past 5-6 years with studies showing good results. Unfortunately, botulinum toxin A is not a permanent solution, and patients require repeat injections every 6-8 months to maintain benefits. Psychotherapy has been beneficial in a small number of cases. Percutaneous computed tomography-guided phenol sympathicolysis achieved good results but has a high long-term failure rate. Surgery has also been shown to successfully reduce hyperhidrosis but, like other therapies, has several complications and patients need to be informed of these prior to undergoing surgery. The excision of axillary sweat glands can cause unsightly scarring and transthoracic sympathectomy (either open or endoscopic) can be associated with complications of compensatory and gustatory hyperhidrosis, Horner syndrome and neuralgia, some of which patients may find worse than the condition itself.
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Affiliation(s)
- Maureen Connolly
- Bristol Dermatology Centre, Bristol Royal Infirmary, Bristol, UK
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40
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Said S, Meshkinpour A, Carruthers A, Carruthers J. Botulinum toxin A: its expanding role in dermatology and esthetics. Am J Clin Dermatol 2004; 4:609-16. [PMID: 12926979 DOI: 10.2165/00128071-200304090-00003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The use of botulinum toxin A in cosmetic dermatology has increased in popularity due to the efficacy and relative safety of the treatment. Botulinum toxin A is one of eight exotoxins produced by Clostridium botulinum, a Gram-positive, spore-forming anaerobe. Flaccid paralysis results from the denervation of muscle fibers at the neuromuscular junction after botulinum toxin A administration. While treating blepharospasm, the Carruthers incidentally found that botulinum toxin A improved glabellar frown lines. Dynamic rhytides occur in areas of dynamic motion. These types of lines may be improved with botulinum toxin A. There are two types of botulinum toxin A commercially available (BOTOX and Dysport); only BOTOX is currently available in the US. The efficacy and tolerability of BOTOX was best demonstrated with a multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines in 264 patients. There was a significantly greater reduction in glabellar line severity with BOTOX. The effect was maintained for the duration of the study (120 days). There was low occurrence (5.4%) of mostly mild blepharoptosis in the BOTOX group. In another prospective study, it was found that about 1% of BOTOX patients reported severe headache. Botulinum toxin A can provide an alternative treatment of palmar and axillary hyperhidrosis when options such as topical agents (aluminum chloride) and iontophoresis have failed.
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Affiliation(s)
- Samireh Said
- University of California, Irvine, California, USA.
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41
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Abstract
Focal idiopathic excessive eccrine sweating presents most commonly as an affliction of three anatomically distinct area: the axillae, the palms and soles, and the upper face. The true incidence is not known, but about half of the patients referred to us with this condition have at least one first-degree relative similarly affected. Only a fraction of patients afflicted are thought to seek medical care because of the social stigma, lack of understanding on the part of medical providers as to the cause and nature of the problem, and, until now, lack of effective nonsurgical therapy. A large social sample is required to accurately measure both the incidence and the exact nature of the genetic influence.
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Affiliation(s)
- Richard G Glogau
- Department of Dermatology, School of Medicine, University of California, San Francisco, San Francisco, California 94117-3685, USA.
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42
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Hund M, Rickert S, Kinkelin I, Naumann M, Hamm H. Does wrist nerve block influence the result of botulinum toxin a treatment in palmar hyperhidrosis? J Am Acad Dermatol 2004; 50:61-2. [PMID: 14699366 DOI: 10.1016/s0190-9622(03)00027-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Treatment of palmar hyperhidrosis with intracutaneous injections of botulinum toxin type A is painful, making anesthesia desirable. However, nerve blocks may be associated with reduced efficacy. In 20 patients with idiopathic palmar hyperhidrosis both palms were treated with intracutaneous injections of botulinum toxin type A after having randomly chosen one hand for anesthesia by median und ulnar nerve block and the other hand for cooling. There was no difference in efficacy of botulinum toxin A treatment between both palms but significantly greater injection pain after cooling compared with nerve block.
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Affiliation(s)
- Martina Hund
- Department of Dermatology, University of Würzburg, Germany
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43
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Abstract
The treatment of focal hyperhidrosis and drooling with neurolysis of the neuroglandular junction is a relatively new and useful technique for managing such obvious conditions and improving the patient's quality of life. The treatment is safe, minimally invasive, and an effective alternative to other treatment modalities.
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Affiliation(s)
- Ib R Odderson
- Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA.
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44
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Abstract
The history of the cosmetic use of botulinum toxin (BTX) must begin with the clinical use of BTX in humans. This came out of Alan Scott's work, which was initially an attempt to find a nonsurgical treatment for some forms of strabismus. Alan Scott put together the idea of Ed Maumenee to use BTX to affect extraocular muscles, Art Jampolsky's electromyographic control delivery system, and Ed Schantz' work on the purification of BTX.
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Affiliation(s)
- Alastair Carruthers
- Division of Dermatology, University of British Columbia, Vancouver, British Columbia, Canada.
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Hayton MJ, Stanley JK, Lowe NJ. A review of peripheral nerve blockade as local anaesthesia in the treatment of palmar hyperhidrosis. Br J Dermatol 2003; 149:447-51. [PMID: 14510973 DOI: 10.1046/j.1365-2133.2003.05593.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Injection of botulinum toxin type A (BTX-A) is an effective method of controlling palmar hyperhidrosis. It is, however, an uncomfortable procedure without adequate anaesthesia. We outline the techniques used, the reasons for them and potential pitfalls that can be avoided, with an outline of the neural anatomy relevant to the palmar injection of BTX-A. We have been using peripheral nerve blockade as local anaesthesia during BTX-A treatment of palmar hyperhidrosis for the last few years, and have found it an effective method of providing pain relief during the procedure, giving greater anaesthesia than that given by topical anaesthetic cream under occlusion and ice. It has been our experience that patients prefer wrist blockade to topical anaesthesia and ice when receiving BTX-A injections for treatment of palmar hyperhidrosis.
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Affiliation(s)
- M J Hayton
- Department of Hand and Upper Limb Surgery, Wrightington Hospital, Appley Bridge, Wigan WN6 9EP, UK
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46
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Andre P. An easy and effective local anaesthesia for treating palmar hyperhidrosis with botulinum toxin injections: the Cry-ac system. J Eur Acad Dermatol Venereol 2003; 17:246-7. [PMID: 12705774 DOI: 10.1046/j.1468-3083.2003.00577_15.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lowe NJ, Yamauchi PS, Lask GP, Patnaik R, Iyer S. Efficacy and safety of botulinum toxin type a in the treatment of palmar hyperhidrosis: a double-blind, randomized, placebo-controlled study. Dermatol Surg 2003; 28:822-7. [PMID: 12269876 DOI: 10.1046/j.1524-4725.2002.02039.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent studies demonstrate that botulinum toxin type A (BTX-A) decreases palmar hyperhidrosis. OBJECTIVE To evaluate the efficacy and safety of BTX-A for palmar hyperhidrosis. METHODS Patients (n = 19) received injections of placebo (normal saline) in one hand and BTX-A in the other. Assessments included gravimetric measurement of sweat production and physician's and patient's rating of severity. Safety evaluations included measuring grip strength. Preliminary 28-day results are reported. RESULTS The mean percentage decrease in gravimetric measurement at day 28 was significantly greater with BTX-A versus placebo. One hundred percent of 17 patients rated the treatment as successful, while only 12% (2/17) rated placebo injection successful. Grip and hand strength were unchanged with either treatment. Only 21% (4/19) reported mild adverse events. CONCLUSION BTX-A injections produce significant improvements in palmar hyperhidrosis without a concomitant decrease in grip or dexterity, or the occurrence of serious adverse events.
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Campanati A, Penna L, Guzzo T, Menotta L, Silvestri B, Lagalla G, Gesuita R, Offidani A. Quality-of-life assessment in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study. Clin Ther 2003; 25:298-308. [PMID: 12637128 DOI: 10.1016/s0149-2918(03)90041-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with hyperhidrosis, a disorder characterized by increased sweat production, experience substantial functional and emotional problems. Botulinum toxin type A (BTX-A) has been shown to be useful in the treatment of hyperhidrosis; however, few studies have considered the effects of treatment on patients' quality of life (QOL). OBJECTIVES The objectives of this study were to assess QOL in patients with focal hyperhidrosis; to investigate whether the impairment in QOL in these patients is related to the type of hyperhidrosis or the number of sites involved; and to compare the changes in QOL and the response to BTX-A treatment in patients with axillary and palmar hyperhidrosis. METHODS Patients with focal primary hyperhidrosis of the axillae, palms, and soles who had experienced decreased QOL and whose condition had not responded to conventional topical and physical therapies were included in this open-label study. Patients completed a self-administered Dermatology Life Quality Index (DLQI) questionnaire before and 2 weeks after treatment with BTX-A. RESULTS All 41 patients had experienced a decrease in QOL as measured by the DLQI. The impairement in QOL was not dependent on the number or types of sites involved. Treatment with BTX-A led to improvement in QOL in all patients, with the median DLQI score decreasing (ie, improving) significantly from pretreatment level (P < 0.001). The improvement in QOL and response to treatment were similar in patients with axillary and palmar hyperhidrosis. CONCLUSIONS Further studies with a longer follow-up period are needed to assess the long-term effects of BTX-A; however, preliminary data from the present study suggest that BTX-A improves QOL in patients with focal hyperhidrosis, independent of the presenting clinical picture.
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Affiliation(s)
- Anna Campanati
- Department of Dermatology, University of Ancona, Ancona, Italy.
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49
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Alric P, Branchereau P, Berthet JP, Léger P, Mary H, Mary-Ané C. Video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis: results in 102 cases. Ann Vasc Surg 2002; 16:708-13. [PMID: 12417930 DOI: 10.1007/s10016-001-0312-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The purpose of this retrospective study was to evaluate the immediate and long-term outcome of video-assisted thoracoscopic sympathectomy for idiopathic palmar hyperhidrosis. Between January 1996 and December 2000, a total of 67 patients underwent 102 sympathectomy procedures with excision of the sympathetic chain between the second and fourth sympathetic ganglion. The mean duration of hospitalization was 1.7 +/- 0.6 days. Five patients were lost to follow-up. Mean duration of follow-up for the 96 sympathectomy procedures in the remaining 62 patients was 38 +/- 6.3 months. Patient outcome showed that video-assisted thoracoscopic sympathectomy is the treatment of choice for idiopathic palmar hyperhidrosis. Long-term patient satisfaction is excellent.
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Affiliation(s)
- Pierre Alric
- Service de Chirurgie Thoracique et Vasculaire, Hôpital Arnaud de Villeneuve, 12 rue du Cheval Vert, 34000 Montpellier, France.
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50
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Abstract
The use of botulinum toxin has revolutionized the treatment of facial lines with an incomparable safety record over the past 14 years. The most common used injection sites are shown in Fig. 9. With the recent FDA approval for Botox in the treatment of glabellar lines, its use will likely increase dramatically. It is essential that practitioners have a detailed and specific knowledge of the facial and neck musculature to be injected to minimize untoward side effects, especially in the early days of new users' learning curve. The specifics of the dilutions and units per amount used for the various different commercial forms of botulinum toxin types A and B need to be understood fully and standardized together with the potential for antigenicity with the higher protein load of type B. In addition, specific indications for the use of botulinum toxin as adjunctive therapy for specific facial surgical procedures (i.e., blepharoplasty, surgical brow lift, and laser resurfacing) will become better understood. [figure: see text] Finally, even though the anatomy of the facial musculature is well described, individual differences in men and women, in different population groups, and in tissue qualities, such as turgor and elasticity [87], are important factors to be considered before undertaking botulinum toxin injections. It is likely that the use of specific measuring devices, such as digital imaging, will further help define the use of botulinum toxin for different muscle groups and facial aesthetic indications.
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Affiliation(s)
- Jennifer Clay Cather
- Texas Dermatology Research Institute, Baylor Medical University, Dallas, TX, USA.
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