(head) Use of botulinum toxin to treat hyperhidrosis. (intro) Dr Harry Singh shares with readers how to treat hyperhidrosis using botulinum toxin

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1 (head) Use of botulinum toxin to treat hyperhidrosis (intro) Dr Harry Singh shares with readers how to treat hyperhidrosis using botulinum toxin (biog) Dr Harry Singh BChD MFGDP has been carrying out facial aesthetics since 2002 and has treated over 3,000 cases. In his last dental practice (focused on aesthetics) he ended up performing more facial aesthetics than dentistry. Due to the very high profit margins associated with facial aesthetics, he decided to concentrate on facial aesthetics and currently has over 700 facial aesthetic patients. He is not only a skillful facial aesthetician but also a keen marketer, which he feels is vital to attract and retain patients requesting facial aesthetic services. He has published numerous articles on the clinical and non-clinical aspects of facial aesthetics, and spoken at dental and facial aesthetics conferences on these topics. He was shortlisted at the Private Dentistry Awards in 2012 and 2013 in the Best Facial Aesthetics Clinic category and a finalist in 2012 at MyFaceMyBody for the Best Aesthetics Clinic. You can download a video Getting Started in Facial Aesthetics free of charge at (body copy) Hyperhidrosis is commonly referred to as excessive sweating and studies have estimated that 3% 1 of the population are affected by this condition. This article will concentrate on the armpits (axillary hyperhidrosis), however be aware that hyperhidrosis can occur either specifically on the hands and feet (palmoplantar hyperhidrosis) and groin, but also, generally, anywhere on the body as a secondary condition. (sub) Aetiology Hyperhidrosis can either be primary or secondary. Primary hyperhidrosis tends to start in late adolescence and affects men and women equally. Primary hyperhidrosis is caused by an exaggerated response to increased body temperature. Sweating is a natural process mediated by the sympathetic nervous system that the body produces in response to external stimuli, such as heat and stress, and is regulated by the hypothalamus. In hyperhidrosis, there is excessive

2 sweating caused by the hyper function of the eccrine sweat glands; much more than is needed to regulate body temperature. Secondary hyperhidrosis may be due to a number of medical conditions such as, but not limited to, certain medications, hormonal imbalance, thyroid problems, diabetes and obesity. (sub) Clinical presentation You cannot underestimate the physical and psychological effects of this condition on the patient presenting to you. 2 These patients will change their lifestyle to minimise their condition. For example, I have had some patients that have never worn coloured clothing because sweat patches would show up. This condition is extremely debilitating with significant impairment in activities of daily living, social interactions and occupational activities. 3 The NHS choices website 4 offers some helpful advice for those who suffer from this condition: - Avoid known triggers that make your sweating worse, such as spicy foods and alcohol - Use antiperspirant spray frequently, rather than deodorants - Avoid wearing tight, restrictive clothing and man-made fibres, such as nylon - Wearing black or white clothing can help to minimise the signs of sweating - Armpit shields can help to absorb excessive sweat and protect your clothes. Sweat is an odourless liquid, however when it decomposes, as a result of bacteria, it produces an unpleasant smell. (sub) Diagnosis A thorough history and examination is needed initially to determine whether you are dealing with primary or secondary hyperhidrosis and whether is it is generalised or localised. The most common type of hyperhidrosis is primary focal hyperhidrosis. Once the diagnosis of primary focal hyperhidrosis is established, we can then evaluate the severity of it. Secondary hyperhidrosis must be ruled out first before a diagnosis of secondary hyperhidrosis can be made. 5 nicola 11/12/ :31 Comment [1]: Is this right? Doesn't make sense to me I'm afraid

3 The International Hyperhidrosis Society has produced a hyperhidrosis disease severity scale to assist patients and practitioners before and after treatment. The patient would rate the severity of their hyperhidrosis: 1. My underarm sweating is never noticeable and never interferes with my daily activities 2. My underarm sweating is tolerable but sometimes interferes with my daily activities 3. My underarm sweating is barely tolerable and frequently interferes with my daily activities 4. My underarm sweating is intolerable and always interferes with my daily activities. A more scientific and accurate way to test the severity is to establish the rate of sweat production (expressed by milligrams per minute) by the iodine starch test or the ninhydrin test. I would reserve these tests for when the patient is required to be referred to a specialist. (sub) Treatment options There are a number of treatment options available, including: Lasers carried out under local anaesthetic, the laser destroys the sweat gland. This treatment is known as laser sweat ablation Microwaves these cause thermal ablation via dielectric heating 6 Pharmarcotherapy initially aluminum chloride-based antiperspirants will be tried. Then you can look at anticholinergic agents that inhibit the binding of acetylcholine to the cholinergic receptor Then we have neuromuscular blocking agents botulinum toxin. Licence was granted by the FDA in 2001 for botulinum toxin to treat axillary hyperhidrosis. Botulinum toxin has been proved to be safe and effective for the treatment of axillary hyperhidrosis. 7 Botulinum toxin A (BTX-A) blocks the smooth muscle activity of the sweat glands. BTX-A inhibits acetylcholine release at the neuromuscular junction and in nicola 11/12/ :31 Comment [2]: Can we get a UK date and organisation for this instead of US? cholinergic autonomic neurons. Compared to treating the face with BTX-A, under the arms seem to have a faster onset of action and greater diffusion. Studies have shown a decrease of between 81.4% 8 9 and 76.5% in sweat production two weeks following BTX-A treatment. BTX-A can be considered for facial hyperhidrosis. This condition can occur on the forehead, upper lip, nasolabial folds and malar areas. When considering the forehead, the injections are placed superficially and high up, near the hairline.

4 Surgery should only be considered once all the other options have been explored. The surgical approach consists of destroying small areas of the sympathetic chain, which interrupts the nerves that stimulate the sweat glands. This is also known as ETS endoscopic thoracic sympathectomy. (sub) Pre-treatment Normal protocols in terms of medical history and consent must be followed. Usual contra-indications with BTX-A apply such as pregnancy, breast feeding, medications that may interfere with neuromuscular transmission and neuromuscular disorders. Careful selection of patients is critical to produce the desired result. The patient is instructed to shave any hair prior to the appointment. In addition they are not allowed to use any antiperspirant 24 hours before their appointment. Pain associated with these intra-dermal injections is reported to be minimal, however a topical anaesthetic can be used to minimise any potential discomfort. Different preparations, dilutions and dosages have been reported in different studies. In my experience dilution does not seem to alter the diffusion pattern. My preferred treatment protocol is to use 0.63ml of 0.9% bacteriostatic saline in 1 vial of Azzalure. This gives me 125 Speywood units per vial and then I use 1 vial (125 Speywood units) per armpit. (sub) During treatment The area is thoroughly cleansed prior to markings (Figure 1). The injected area is marked with a non-tattooing pencil (Figure 2). This area is normally darker and indicated by the locality of the hair follicles. In addition, ask the patient if they notice sweating coming from any particular areas. A starch iodine test can be considered to delineate the affected area accurately. Then proceed to mark out as a grid with 1cm squares (Figure 3). Take a photograph of the markings for future reference. I will then inject the vial of Azzalure containing 125 Speywood units divided by the number of squares. I use an insulin BD 0.5ml syringe 30G 13mm.

5 On average, I find that there are normally 12 x 1cm squares; therefore I would inject 10 Speywood units of Azzalure per 1cm square. The injections are placed superficially and intra-dermally. Regular changing of the needle is required due to the number of injections causing the needle to become blunt and therefore more uncomfortable for the patient. The most common side effects following treatment (occurring in 3% to 10% of patients) include injection site pain and bleeding, sweating in other parts of the body, flu-like symptoms, headache, fever, itching and anxiety. nicola 11/12/ :42 Comment [3]: Is there a ref for this? Ask the patient to be aware of any sweating before their review appointment and to pinpoint any specific areas. You may ask them to exercise to increase the body temperature to allow them to sweat, and to observe any excessive sweating. (sub) Post-treatment Ask the patient if they have noticed any sweat and to pinpoint the area; top up accordingly with BTX-A. In my experience my patients achieve good results in 7 months and this is confirmed by numerous studies. 10 (sub) Summary Emerging therapies are being developed constantly to help with the treatment of axillary hyperhidrosis. More research is needed in the field of lasers, ultrasound and radiofrequency. 11 (sub) References 1. David R Strutton et al. US Prevalence of Hyperhidrosis and Impact on Individuals with Auxillary Hyperhidrosis: Results from a national survey, Journal of the American Academy of Dermatology, 51(2004) Katherine M Gross et al. Elevated Social Stress Levels and Depressive Symptoms in Primary Hyperhidrosis, PLOS ONE, 9(2014) e92412

6 3. Hamm, Henning MD. Impact of hyperhidrosis on quality of life and its assessment, Dermatologic Clinics 32:4 (2014): Moraites, Eleni MD, et al. Incidence and prevalence of hyperhidrosis, Dermatologic Clinics 32:4 (2014): Camelia Gabriel et al. Dielectric parameters relevant to microwave dielectric heating, Chemical Society Reviews, 27 (1998) Trindade de Almeida, Ada Regina MD & Montagner, Suelen MD. Botulinum toxin for axillary hyperhidrosis, Dermatologic Clinics 32:4 (2014): Naumann M, Lowe NJ (on behalf of the BOTOX hyperhidrosis clinical study group) 2001 Botulinum Toxin Type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial, British Medical Journal 323: Glogau, RG. Botulinum A neurotoxin for axillary hyperhidrosis. No sweat Botox, Dermatol Surg 24 (1998): Markus Naurmann et al. Botulinum Toxin Type A is a Safe and Effective Treatment for Axillary Hyperhidrosis Over 16 Months, Archives of Dermatology, 139(2003) Glaser, Dee Anna MD & Galperin, Timur DO. Managing hyperhidrosis: emerging therapies, Dermatologic Clinics 32:4 (2014): ENDS