Videos of Surgical Procedures in Dermatology
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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Octubre | 636 | 100 | 736 |
| 2024 Septiembre | 663 | 97 | 760 |
| 2024 Agosto | 839 | 118 | 957 |
| 2024 Julio | 902 | 151 | 1053 |
| 2024 Junio | 904 | 138 | 1042 |
| 2024 Mayo | 981 | 100 | 1081 |
| 2024 Abril | 802 | 117 | 919 |
| 2024 Marzo | 792 | 153 | 945 |
| 2024 Febrero | 750 | 135 | 885 |
| 2024 Enero | 787 | 162 | 949 |
| 2023 Diciembre | 620 | 110 | 730 |
| 2023 Noviembre | 730 | 153 | 883 |
| 2023 Octubre | 674 | 165 | 839 |
| 2023 Septiembre | 669 | 189 | 858 |
| 2023 Agosto | 578 | 155 | 733 |
| 2023 Julio | 537 | 298 | 835 |
| 2023 Junio | 542 | 367 | 909 |
| 2023 Mayo | 341 | 526 | 867 |
| 2023 Abril | 226 | 350 | 576 |
| 2023 Marzo | 236 | 229 | 465 |
| 2023 Febrero | 145 | 199 | 344 |
| 2023 Enero | 126 | 218 | 344 |
| 2022 Diciembre | 101 | 230 | 331 |
| 2022 Noviembre | 71 | 217 | 288 |
| 2022 Octubre | 61 | 206 | 267 |
| 2022 Septiembre | 77 | 286 | 363 |
| 2022 Agosto | 87 | 305 | 392 |
| 2022 Julio | 68 | 383 | 451 |
| 2022 Junio | 84 | 168 | 252 |
| 2022 Mayo | 152 | 382 | 534 |
| 2022 Abril | 185 | 332 | 517 |
| 2022 Marzo | 154 | 387 | 541 |
| 2022 Febrero | 103 | 362 | 465 |
| 2022 Enero | 90 | 275 | 365 |
| 2021 Diciembre | 115 | 329 | 444 |
| 2021 Noviembre | 103 | 372 | 475 |
| 2021 Octubre | 87 | 415 | 502 |
| 2021 Septiembre | 72 | 303 | 375 |
| 2021 Agosto | 59 | 282 | 341 |
| 2021 Julio | 78 | 309 | 387 |
| 2021 Junio | 82 | 493 | 575 |
| 2021 Mayo | 84 | 545 | 629 |
| 2021 Abril | 140 | 619 | 759 |
| 2021 Marzo | 78 | 332 | 410 |
| 2021 Febrero | 82 | 226 | 308 |
| 2021 Enero | 41 | 176 | 217 |
| 2020 Diciembre | 65 | 122 | 187 |
| 2020 Noviembre | 27 | 120 | 147 |
| 2020 Octubre | 37 | 104 | 141 |
| 2020 Septiembre | 55 | 113 | 168 |
| 2020 Agosto | 32 | 133 | 165 |
| 2020 Julio | 52 | 135 | 187 |
| 2020 Junio | 58 | 112 | 170 |
| 2020 Mayo | 39 | 176 | 215 |
| 2020 Abril | 38 | 109 | 147 |
| 2020 Marzo | 56 | 96 | 152 |
| 2020 Febrero | 14 | 126 | 140 |
| 2020 Enero | 2 | 102 | 104 |
| 2019 Diciembre | 8 | 120 | 128 |
| 2019 Noviembre | 4 | 78 | 82 |
| 2019 Octubre | 0 | 95 | 95 |
| 2019 Septiembre | 9 | 202 | 211 |
| 2019 Agosto | 4 | 287 | 291 |
| 2019 Julio | 4 | 288 | 292 |
| 2019 Junio | 5 | 278 | 283 |
| 2019 Mayo | 8 | 416 | 424 |
| 2019 Abril | 2 | 483 | 485 |
| 2019 Marzo | 2 | 421 | 423 |
| 2019 Febrero | 4 | 303 | 307 |
| 2019 Enero | 0 | 480 | 480 |
| 2018 Diciembre | 4 | 364 | 368 |
| 2018 Noviembre | 2 | 28 | 30 |
| 2018 Octubre | 6 | 1 | 7 |
| 2018 Septiembre | 12 | 62 | 74 |
| 2018 Agosto | 0 | 227 | 227 |
| 2018 Julio | 0 | 183 | 183 |
| 2018 Junio | 0 | 146 | 146 |
| 2018 Mayo | 1 | 183 | 184 |
| 2018 Abril | 0 | 161 | 161 |
| 2018 Marzo | 8 | 141 | 149 |
| 2018 Febrero | 339 | 117 | 456 |
| 2018 Enero | 334 | 128 | 462 |
| 2017 Diciembre | 274 | 101 | 375 |
| 2017 Noviembre | 219 | 100 | 319 |
| 2017 Octubre | 238 | 92 | 330 |
| 2017 Septiembre | 179 | 67 | 246 |
| 2017 Agosto | 179 | 79 | 258 |
| 2017 Julio | 213 | 96 | 309 |
| 2017 Junio | 241 | 122 | 363 |
| 2017 Mayo | 238 | 122 | 360 |
| 2017 Abril | 171 | 83 | 254 |
| 2017 Marzo | 175 | 67 | 242 |
| 2017 Febrero | 191 | 39 | 230 |
| 2017 Enero | 124 | 39 | 163 |
| 2016 Diciembre | 156 | 26 | 182 |
| 2016 Noviembre | 180 | 39 | 219 |
| 2016 Octubre | 188 | 32 | 220 |
| 2016 Septiembre | 260 | 26 | 286 |
| 2016 Agosto | 203 | 34 | 237 |
| 2016 Julio | 98 | 27 | 125 |
| 2016 Junio | 7 | 16 | 23 |
| 2016 Mayo | 7 | 17 | 24 |
| 2016 Abril | 8 | 8 | 16 |
| 2016 Marzo | 10 | 5 | 15 |
| 2016 Febrero | 12 | 11 | 23 |
| 2016 Enero | 13 | 5 | 18 |
| 2015 Diciembre | 9 | 1 | 10 |
| 2015 Noviembre | 1 | 7 | 8 |
| 2015 Octubre | 8 | 12 | 20 |
| 2015 Septiembre | 5 | 10 | 15 |
| 2015 Agosto | 13 | 1 | 14 |
| 2015 Julio | 93 | 12 | 105 |
| 2015 Junio | 114 | 8 | 122 |
| 2015 Mayo | 117 | 15 | 132 |
| 2015 Abril | 71 | 14 | 85 |
| 2015 Marzo | 63 | 8 | 71 |
| 2015 Febrero | 42 | 5 | 47 |
| 2015 Enero | 42 | 6 | 48 |
| 2014 Diciembre | 40 | 7 | 47 |
| 2014 Noviembre | 35 | 8 | 43 |
| 2014 Octubre | 42 | 8 | 50 |
| 2014 Septiembre | 58 | 4 | 62 |
| 2014 Agosto | 142 | 19 | 161 |
| 2014 Julio | 178 | 20 | 198 |
| 2014 Junio | 143 | 14 | 157 |
| 2014 Mayo | 17 | 2 | 19 |
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