Botulinum toxin in the treatment of axillary hyperhidrosis

A preliminary study of painless and effective transdermal botulinum toxin A delivery by jet nebulization for treatment of primary hyperhidrosis

Background

Hyperhidrosis is a chronic disease characterized by increased sweat production. Local injections of botulinum toxin A (BTX-A) have been extensively used for treatment of primary hyperhidrosis (idiopathic). The current treatment for this condition involves several intradermal injections, resulting in poor patient compliance due to injection-related pain. Therefore, new protocols, including an improved anesthetic regimen, are required.

Aim

We designed the present study to determine whether JetPeel™-3, a medical device used for transdermal delivery of drugs by jet nebulization, could be used to deliver lidocaine prior to the standard multiple BTX-A injections or deliver lidocaine together with BTX-A in order to determine the protocol giving better results in terms of procedure-related pain, sweating, and patient satisfaction in subjects affected by primary axillary, palmar or plantar hyperhidrosis.

Materials and methods

Twenty patients with a visual analog scale (VAS) sweating score ≥ 8 cm were randomized to receive lidocaine 2% (5 mL) delivered by JetPeel™-3 followed by multiple injections of BTX-A (100 units) or lidocaine 2% (5 mL) and BTX-A (50 units) delivered together by JetPeel™-3. Effect of treatment on sweating was measured by VAS (0= minimum sweating; 10= maximum sweating) at 3-month follow-up. Pain induced by the procedure was assessed by VAS (0= minimum pain; 10= maximum pain) immediately after the procedure. Patient satisfaction was assessed at 3-month follow-up using a 5-point scale (1= not at all satisfied; 2= not satisfied; 3= partially satisfied; 4= satisfied; 5= highly satisfied).

Results

Both treatment modalities reduced sweating at 3-month follow-up, if compared with baseline (all P<0.001). Delivery of lidocaine and BTX-A by JetPeel™-3 resulted in lower procedure-related pain and reduced sweating, if compared with lidocaine delivered by JetPeel™-3 followed by multiple BTX-A injections (all P<0.001). Patient satisfaction with the procedure was higher in the group receiving lidocaine and BTX-A treatment by JetPeel™-3, if compared with lidocaine delivered by JetPeel™-3 followed by multiple BTX-A injections (P<0.001). No side effects were observed in both groups.

Conclusion

Lidocaine and BTX-A can be safely delivered together by JetPeel™-3 to treat primary palmar, plantar and axillary hyperhidrosis, resulting in lower procedure-related pain, improved sweating and higher patient satisfaction, if compared with lidocaine delivered by JetPeel™-3 followed by standard BTX-A injection therapy. Our protocol delivering lidocaine and BTX-A together by JetPeel™-3 requires a reduced quantity of BTX-A, further supporting the use of the transdermal drug delivery by jet nebulization over standard injection therapy for treatment of primary hyperhidrosis.

Treatment of primary axillary hyperhidrosis with botulinum toxin type a: our experience in 50 patients from 2007 to 2010

Background. Local injections of Botulinum toxin type A (BTX-A) are an effective and safe solution for primary bilateral axillary hyperhidrosis. Traditional treatments are often ineffective and difficult to tolerate. This study was performed to assess the efficacy and safety of Botulinum toxin type A in the treatment of these diseases and to evaluate the reliability of patient's subjective rating in the timing of repeat injections. Methods. From 2007 to 2008, we included in the study and treated a total of 50 patients, and we used the Minor's iodine test and the hyperhidrosis diseases severity scale as initial inclusion criteria and also for evaluating the followup, comparing to patient's subjective rating. We used also a specific questionnaire to evaluate the level of pain, the onset of the effect, any eventual adverse effect of the treatment, the onset of compensatory hyperhidrosis, and the global grade of satisfaction. The data were analyzed using standard statistical methods. Results. 88% of patients were totally satisfied and all patients repeated the treatment during all the study. The symptom-free interval was in median 6 months with an average improving of HDSS of 1.5 points. In 86%, there was a complete accordance between the subjective patient's demand of the repetition of the treatment and the positivity to Minor test and HDSS. No major side effects happened. Conclusion. Local injections of Botulinum toxin type A (BTX-A) result in an effective and safe solution for bilateral axillary primary hyperhidrosis for the absence of significant morbidity, side effects, and lack of efficacy or duration. The only defects are the need of repetition of the treatment and relative costs.

Botulinum toxin for hyperhidrosis: a review

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.

Efficacy of botulinum toxin type A in the treatment of focal axillary hyperhidrosis

BACKGROUND

Local intradermal injection of botulinum toxin Type A has become a recognized treatment for axillary hyperhidrosis. This study has investigated the efficacy of this method of treatment in terms of symptom-free interval between treatments and patients' satisfaction. We also investigated the reliance on patients' subjective assessment of the recurrence of symptoms in determining the timing of repeat injections.

METHODS

All patients referred to our clinic between May 2001 and December 2005 with a diagnosis of focal primary axillary hyperhidrosis were included in this study. Data were collected prospectively in a standard proforma. Every patient received a questionnaire to complete over a 4-week period. The questionnaire included visual analogue scales for periprocedural pain, degree of dryness, satisfaction, regret, and complications. Final symptom-free interval was recorded when the patient requested a repeat injection. The data were recorded on a spreadsheet and analyzed using standard statistical methods.

RESULTS

A total of 52 consecutive patients and 238 axillary injections were analyzed. The symptom-free interval ranged from 3 to 14 months with a median of 5.97 months. There were no significant complications from this treatment modality. A total of 97% of the patients were highly satisfied with only 1 patient regretting the treatment.

CONCLUSION

Botulinum toxin Type A is an effective and well-tolerated treatment for axillary hyperhidrosis. Timing of repeat injections as determined subjectively by patients is comparable to studies using colorimetric and gravimetric techniques to quantify the severity of sweating prior to the administration of repeat injections. The authors have indicated no significant interest with commercial supporters.

A randomized pilot study comparing the action halos of two commercial preparations of botulinum toxin type A

BACKGROUND

The determination of the action halos of botulinum toxin type A aids in targeting specific muscles and/or sweat glands, thereby preventing the occurrence of side effects.

OBJECTIVES

The objective of this study was to compare the action halos of two commercial preparations of botulinum toxin type A, Dysport (Ipsen, Slough, UK) and BOTOX (Allergan, Irvine, CA).

MATERIAL AND METHODS

Eighteen volunteers received applications of both products into randomized sides of the frontalis muscle. Equivalent doses of 5 U of Dysport and 2 U of BOTOX were injected using the same technique, in the same volume (0.02 mL), and at a controlled depth. Twenty-eight days later, clinical and photographic assessments were performed.

RESULTS

All the areas around the injected points were regular, round, or slightly oval and showed similar effects in the muscles and sweat glands. No statistically significant differences were observed between the mean sizes of the diameters of the halos produced by the two products.

CONCLUSION

Injections of Dysport and BOTOX at an equivalence ratio of 2.5:1 U, respectively, applied at the same volume and depth, using the same technique resulted in similar action halos with regard to muscular and sweat gland activity. Both products seem to be safe and very predictable.

A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee

BACKGROUND

Hyperhidrosis can have profound effects on a patient's quality of life. Current treatment guidelines ignore disease severity.

OBJECTIVE

The objective was to establish clinical guidelines for the recognition, diagnosis, and treatment of primary focal hyperhidrosis.

METHODS AND MATERIALS

A working group of eight nationally recognized experts was convened to develop the consensus statement using an evidence-based approach.

RECOMMENDATIONS

An algorithm was designed to consider both disease severity and location. The Hyperhidrosis Disease Severity Scale (HDSS) provides a qualitative measure that allows tailoring of treatment. Mild axillary, palmar, and plantar hyperhidrosis (HDSS score of 2) should initially be treated with topical aluminum chloride (AC). If the patient fails to respond to AC therapy, botulinum toxin A (BTX-A; axillae, palms, soles) and iontophoresis (palms, soles) should be the second-line therapy. In severe cases of axillary, palmar, and plantar hyperhidrosis (HDSS score of 3 or 4), both BTX-A and topical AC are first-line therapy. Iontophoresis is also first-line therapy for palmar and plantar hyperhidrosis. Craniofacial hyperhidrosis should be treated with oral medications, BTX-A, or topical AC as first-line therapy. Local surgery (axillary) and endoscopic thoracic sympathectomy (palms and soles) should only be considered after failure of all other treatment options.

CONCLUSIONS

These guidelines offer a rapid method to assess disease severity and to treat primary focal hyperhidrosis according to severity.