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Botulinum Toxin Injection Technique for Axillary Hyperhidrosis
Técnica de infiltración de toxina botulínica en hiperhidrosis axilar
J. del Boz
, L. Padilla-España, J.M. Segura-Palacios
Corresponding author
Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain
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Padilla-España, J.M. Segura-Palacios" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "del Boz" "email" => array:1 [ 0 => "javierdelboz@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Padilla-España" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Segura-Palacios" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Costa del Sol, Marbella, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Técnica de infiltración de toxina botulínica en hiperhidrosis axilar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1105 "Ancho" => 1658 "Tamanyo" => 356494 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Division of the axilla into quadrants, with the sites of injection situated in the center.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">An approved indication for botulinum toxin (BT) is for the treatment of severe and persistent primary hyperhidrosis of the axilla that interferes with the activities of daily living and that is resistant to topical treatment. This is currently the only approved indication for botulinum toxin type A (BTA), marketed as Botox and presented in the form of vials containing 100<span class="elsevierStyleHsp" style=""></span>units.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Prior to indicating this procedure, the medical history must be taken, a physical examination performed, and specific additional tests done as required to exclude possible causes of secondary hyperhidrosis and avoid the symptomatic treatment of hyperhidrosis without the diagnosis and/or treatment of an underlying disease.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical improvement usually develops within a week after the injection.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> The injection of BT can be repeated when the clinical effect of the previous injection declines and the specialist considers it necessary; however, it is not advisable to repeat injections at intervals of less than 16 weeks.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Description of the Technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">Prior to injection, the area of axillary hyperhidrosis to be treated can be identified using the starch-iodine technique (the Minor test). The quadrants to be treated are defined and antiseptic is applied. The quadrants can be marked on a transparent dressing rather than on the skin in order to avoid the risk that the marks become blurred by the sweat.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The discomfort associated with the procedure can be minimized by the subcutaneous injection of local anesthetic, or topical anesthesia can be applied prior to starting the procedure.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The vial of 100<span class="elsevierStyleHsp" style=""></span>units of BTA is reconstituted by dissolution in 0.9% saline solution (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); though the volume of solution for reconstitution of the vial can be varied, it is usually done with 5<span class="elsevierStyleHsp" style=""></span>mL, which will give us a concentration of 2<span class="elsevierStyleHsp" style=""></span>units in every 0.1<span class="elsevierStyleHsp" style=""></span>mL of the resulting solution.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">As a rule, 50<span class="elsevierStyleHsp" style=""></span>U are administered into each axilla,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> injected intradermally using sterile 30<span class="elsevierStyleHsp" style=""></span>gauge needles, making the injections as equally spaced as possible over the area of hyperhidrosis, separated by 1 to 2<span class="elsevierStyleHsp" style=""></span>cm (depending on the size of the area to be treated). Typically, 25 injections are made per axilla (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), injecting 0.1<span class="elsevierStyleHsp" style=""></span>mL (2<span class="elsevierStyleHsp" style=""></span>units) at each site.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Precautions and Contraindications</span><p id="par0035" class="elsevierStylePara elsevierViewall">There is no approved indication for the use of BTA in the treatment of hyperhidrosis of the axilla in patients under 18 years of age or in pregnant or breastfeeding women as there is insufficient data concerning safety and efficacy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The use of BTA in patients with neuromuscular disorders must be performed with extreme caution and under strict supervision due to the risk of onset of excessive muscle weakness.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The procedure is contraindicated in patients with known hypersensitivity to BTA or to any of the excipients of the preparation and in patients with infection in the area of the proposed sites of injection.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In theory, the effect of BT can be potentiated by the aminoglycoside antibiotics and spectinomycin, as well as by other drugs that interfere with neuromuscular transmission, such as the neuromuscular blocking agents.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Variations in the clinical effect after repeated use of BTA may be due to the use of different procedures for reconstitution of the vial, different intervals between injection, and slight variations in the potency of the toxin due to the biological process used for its synthesis. The formation of neutralizing antibodies to BTA can reduce the effectiveness of treatment; injection of the minimum effective dose at the maximum possible interval between injections is therefore recommended to minimize the risk of formation of these antibodies.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Complications</span><p id="par0060" class="elsevierStylePara elsevierViewall">Complications of this technique are uncommon (11% according to the summary of product characteristics<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>) and the large majority are minor and transitory.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> As with any injection, the technique can give rise to infection, pain, inflammation, paresthesia, hypoesthesia, swelling, edema, erythema, and localized hemorrhage or hematomas (often related more to the previous injection of local anesthetic).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The pain associated with insertion of the needles and/or anxiety can give rise to vasovagal reactions. In very rare cases (0.7%), transitory muscle weakness can develop in the upper limb. In addition, about 4.5% of patients develop excess sweating in untreated areas (including areas without previous hyperhidrosis), and this can persist for up to a month.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Severe or immediate hypersensitivity reactions, including anaphylaxis, serum sickness, urticaria, soft tissue edema, and dyspnea have been reported rarely.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">The injection of botulinum toxin for the treatment of axillary hyperhidrosis is a simple procedure that is relatively quick to perform and has a low risk of complications.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> The technique produces a high level of satisfaction in a large majority of patients.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The main limitations to the technique are the transitory nature of its effect and the cost of the vial of botulinum toxin.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Description of the Technique" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Precautions and Contraindications" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Complications" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of Interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: del Boz J, Padilla-España L, Segura-Palacios JM. Técnica de infiltración de toxina botulínica en hiperhidrosis axilar. Actas Dermosifiliogr. 2014;105:517–518.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0095" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0040" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1106 "Ancho" => 1659 "Tamanyo" => 466426 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Material required.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1105 "Ancho" => 1658 "Tamanyo" => 356494 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Division of the axilla into quadrants, with the sites of injection situated in the center.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 43209881 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Botox summary of product characteristics. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 92 | 16 | 108 |
| 2024 October | 636 | 100 | 736 |
| 2024 September | 663 | 97 | 760 |
| 2024 August | 839 | 118 | 957 |
| 2024 July | 902 | 151 | 1053 |
| 2024 June | 904 | 138 | 1042 |
| 2024 May | 981 | 100 | 1081 |
| 2024 April | 802 | 117 | 919 |
| 2024 March | 792 | 153 | 945 |
| 2024 February | 750 | 135 | 885 |
| 2024 January | 787 | 162 | 949 |
| 2023 December | 620 | 110 | 730 |
| 2023 November | 730 | 153 | 883 |
| 2023 October | 674 | 165 | 839 |
| 2023 September | 669 | 189 | 858 |
| 2023 August | 578 | 155 | 733 |
| 2023 July | 537 | 298 | 835 |
| 2023 June | 542 | 367 | 909 |
| 2023 May | 341 | 526 | 867 |
| 2023 April | 226 | 350 | 576 |
| 2023 March | 236 | 229 | 465 |
| 2023 February | 145 | 199 | 344 |
| 2023 January | 126 | 218 | 344 |
| 2022 December | 101 | 230 | 331 |
| 2022 November | 71 | 217 | 288 |
| 2022 October | 61 | 206 | 267 |
| 2022 September | 77 | 286 | 363 |
| 2022 August | 87 | 305 | 392 |
| 2022 July | 68 | 383 | 451 |
| 2022 June | 84 | 168 | 252 |
| 2022 May | 152 | 382 | 534 |
| 2022 April | 185 | 332 | 517 |
| 2022 March | 154 | 387 | 541 |
| 2022 February | 103 | 362 | 465 |
| 2022 January | 90 | 275 | 365 |
| 2021 December | 115 | 329 | 444 |
| 2021 November | 103 | 372 | 475 |
| 2021 October | 87 | 415 | 502 |
| 2021 September | 72 | 303 | 375 |
| 2021 August | 59 | 282 | 341 |
| 2021 July | 78 | 309 | 387 |
| 2021 June | 82 | 493 | 575 |
| 2021 May | 84 | 545 | 629 |
| 2021 April | 140 | 619 | 759 |
| 2021 March | 78 | 332 | 410 |
| 2021 February | 82 | 226 | 308 |
| 2021 January | 41 | 176 | 217 |
| 2020 December | 65 | 122 | 187 |
| 2020 November | 27 | 120 | 147 |
| 2020 October | 37 | 104 | 141 |
| 2020 September | 55 | 113 | 168 |
| 2020 August | 32 | 133 | 165 |
| 2020 July | 52 | 135 | 187 |
| 2020 June | 58 | 112 | 170 |
| 2020 May | 39 | 176 | 215 |
| 2020 April | 38 | 109 | 147 |
| 2020 March | 56 | 96 | 152 |
| 2020 February | 14 | 126 | 140 |
| 2020 January | 2 | 102 | 104 |
| 2019 December | 8 | 120 | 128 |
| 2019 November | 4 | 78 | 82 |
| 2019 October | 0 | 95 | 95 |
| 2019 September | 9 | 202 | 211 |
| 2019 August | 4 | 287 | 291 |
| 2019 July | 4 | 288 | 292 |
| 2019 June | 5 | 278 | 283 |
| 2019 May | 8 | 416 | 424 |
| 2019 April | 2 | 483 | 485 |
| 2019 March | 2 | 421 | 423 |
| 2019 February | 4 | 303 | 307 |
| 2019 January | 0 | 480 | 480 |
| 2018 December | 4 | 364 | 368 |
| 2018 November | 2 | 28 | 30 |
| 2018 October | 6 | 1 | 7 |
| 2018 September | 12 | 62 | 74 |
| 2018 August | 0 | 227 | 227 |
| 2018 July | 0 | 183 | 183 |
| 2018 June | 0 | 146 | 146 |
| 2018 May | 1 | 183 | 184 |
| 2018 April | 0 | 161 | 161 |
| 2018 March | 8 | 141 | 149 |
| 2018 February | 339 | 117 | 456 |
| 2018 January | 334 | 128 | 462 |
| 2017 December | 274 | 101 | 375 |
| 2017 November | 219 | 100 | 319 |
| 2017 October | 238 | 92 | 330 |
| 2017 September | 179 | 67 | 246 |
| 2017 August | 179 | 79 | 258 |
| 2017 July | 213 | 96 | 309 |
| 2017 June | 241 | 122 | 363 |
| 2017 May | 238 | 122 | 360 |
| 2017 April | 171 | 83 | 254 |
| 2017 March | 175 | 67 | 242 |
| 2017 February | 191 | 39 | 230 |
| 2017 January | 124 | 39 | 163 |
| 2016 December | 156 | 26 | 182 |
| 2016 November | 180 | 39 | 219 |
| 2016 October | 188 | 32 | 220 |
| 2016 September | 260 | 26 | 286 |
| 2016 August | 203 | 34 | 237 |
| 2016 July | 98 | 27 | 125 |
| 2016 June | 7 | 16 | 23 |
| 2016 May | 7 | 17 | 24 |
| 2016 April | 8 | 8 | 16 |
| 2016 March | 10 | 5 | 15 |
| 2016 February | 12 | 11 | 23 |
| 2016 January | 13 | 5 | 18 |
| 2015 December | 9 | 1 | 10 |
| 2015 November | 1 | 7 | 8 |
| 2015 October | 8 | 12 | 20 |
| 2015 September | 5 | 10 | 15 |
| 2015 August | 13 | 1 | 14 |
| 2015 July | 93 | 12 | 105 |
| 2015 June | 114 | 8 | 122 |
| 2015 May | 117 | 15 | 132 |
| 2015 April | 71 | 14 | 85 |
| 2015 March | 63 | 8 | 71 |
| 2015 February | 42 | 5 | 47 |
| 2015 January | 42 | 6 | 48 |
| 2014 December | 40 | 7 | 47 |
| 2014 November | 35 | 8 | 43 |
| 2014 October | 42 | 8 | 50 |
| 2014 September | 58 | 4 | 62 |
| 2014 August | 142 | 19 | 161 |
| 2014 July | 178 | 20 | 198 |
| 2014 June | 143 | 14 | 157 |
| 2014 May | 17 | 2 | 19 |
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