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Q: Where are the sweat glands located in the skin?
A: They exist at the deep aspect of the dermis, very close to the
interface of the subcutaneous fat and the dermis. To work well, the
BOTOX® Purified Neurotoxin Complex* should be injected in such a way
as to raise a dermal wheal or bump very similar to one that is made
with a tuberculin skin test. If injected too deeply, it dissipates
into the fat and misses the nerve-gland junctions. If too superficial,
it easily bleeds back out of the injection site and is wasted.
Q: How does BOTOX® paralyze the sweat glands?
A: The sweat glands require stimulation by the cholinergic nerve fibers
which are part of the sympathetic autonomic nervous system. These
fibers originate in ganglia located near the spinal cord and extend
up to the undersurface of the skin where they branch into tiny fibers
that extend to the eccrine sweat glands. The BOTOX® inhibits the release
of the chemical messenger acetylcholine which is released at the nerve
endings and is required to stimulate the sweat glands. If there is
no release of acetylcholine, there is no stimulation of the glands.
If there is no stimulation, the glands simply sit there doing nothing
and the skin remains dry.
Q: Why do I have hyperhidrosis?
A: People with hyperhidrosis have higher than normal levels of cholinergic
nerve stimulation of the eccrine sweat glands. This stimulation can
be more or less continuous in some patients, obviously those who sweat
all the time. Or it can be intermittently active, triggered by heat,
anxiety, or physical stimulation like application of creams to the
skin or simply washing the skin. Patients with hyperhidrosis often
report other symptoms suggestive of high rates of sympathetic autonomic
nerve activity: higher resting pulse rate, flushing of the skin, sensations
of warmth, etc. No one knows why this increased autonomic nerve tone
is present. There is clearly a genetic influence, however, as we frequently
see groups of sweaters in the same family.
Q: How do you know exactly where to inject?
A: We can apply a tincture of iodine to the skin and then dust it
lightly with corn starch powder (so-called Minor Starch Test). The
perspiration combines the iodine and glucose in the starch and turns
instantly black which makes identifying the hyperhidrotic areas very
easy. It is mandatory to map out the sweating pattern this way as
the physician can easily miss some of the active areas. We repeat
the test after the treatments to evaluate the presence of any persistent
areas and document the extent to which the sweating has diminished.
Q: Can I treat hands, feet, and underarms
all at the same time?
A: You can certainly treat both underarms at the same time. There
is no danger of muscle weakness in the underarms because the doses
used are relatively small compared to the massive bulk of the muscles
underlying the axillary skin. However, we generally do not like to
treat both palms simultaneously because at least 25% of the patients
get some mild transient weakness of some of the muscles of the fingers
or hand which lasts about 10 days to 2 weeks on average. Therefore
we generally treat one hand and wait a week or two to treat the second
hand.
Also, we do not like to use more than 200 units in one treatment session
regardless of where the BOTOX® is placed. This is because there is
some suggestion in the medical literature that sensitization may occur
when repeate doses of more than 200 units at one time are used. If
one becomes sensitized to the BOTOX® the body manufactures an antibody
against the toxin and it will no longer have any effect whatsoever!
This is the last thing we would want to have happen since it would
mean the drug would be forever useless for the sensitized individual.
Q: How long does it last?
A: We routinely see 6 months of dryness in axillary patients, palmar
patients, and plantar (foot) patients. Some patients stay dry for
periods up to a year after establishing initial dryness.
Q: How many treatments does it take to treat
underarms, palms, feet?
A: The typical axillary sufferer will be treated on both sides at
the initial visit. We like to see the patients again in about two
weeks to touch up any spots still sweating which might have been missed
in the initial treatment session. Palmar patients are more difficult
to treat. We will generally see significant decrease in sweating with
the first injections, but generally for the very heavy sweaters, we
will need to touch up persistent spots at a second visit 7 to 10 days
later. We can begin treating the second hand at that point as well,
and follow-up with a third visit in another 7 to 10 days. Feet are
somewhat easier since the toes are smaller in surface area than the
fingers and do not require as many injections.
Q: Does BOTOX® work for facial sweating?
A: We have successfully treated a number of patients who have sweating
of the anterior scalp and upper forehead. They behave much the same
way as the patients with axillary sweating. The BOTOX® appears to
diffuse fairly well in the upper forehead skin. The periods of dryness
are about the same. Part of the difficulty is knowing how far back
into the scalp to carry the injections. Most of the patients treated
so far are happy with the upper half of the forehead and anterior
1/3 of the scalp treated, but it probably varies a good deal from
patient to the patient.
Q: Can you get compensatory hyperhidrosis
from the use of BOTOX®?
A: No. The effects of the BOTOX® are strictly focal. Since only small
surface areas are treated (axillary skin, palms, soles, upper forehead
etc.) the rest of the skin on the arms, legs, torso, and face sweats
as before. There is no compensatory hyperhidrosis reported and we
have not observed any in the many cases we have treated.
Q: How much does it cost?
A: It depends on the surface area your are trying to block. A smaller
person with small hands, small axillary (underarm) skin, or small
feet will require less medication to treat than a person with larger
hands, feet, underarms, etc. This is because the BOTOX® is injected
in very small amounts, typically .05 ml per site with 2-4 units per
site. The BOTOX® will diffuse a short distance in the axillary skin,
usually 1.0 cm (half inch) in all directions. By overlapping the circles
of diffusion, it will cover the entire axilla if you inject small
amounts spaced about 1.5 cm apart. A typical underarm will require
100 - 120 units total (50 - 60 per armpit). To treat two underarms then typically costs $1200 - $1400.
Palms and soles require more material because the skin is thicker and the drug does not spread as easily through the thicker skin. Therefore you need to space your injections closer together, typically 0.75 cm apart, to cover the palm and fingers. An average hand uses 100 units or more per palm, therefore $2,000 - $2500 for both hands. It works out to be about the same for feet.
Q: Does insurance cover the cost of the treatment?
A: On occasion yes, however, it is a very time consuming and difficult process. Currently our office does not file to insurance for the treatment of hyperhidrosis. Sadly,
most people by now are more than familiar with the reality that the
insurers make money by collecting premiums and denying claims for
payment. Using BOTOX® to treat hyperhidrosis is a so-called "off-label"
use, meaning that, although the drug is FDA approved, at present the
only approved indications are for blepharospasm (twitches around the
eye muscles) and dystonia (involuntary muscle spasm). The company
has not yet applied for nor received FDA approval for the indication
of hyperhidrosis. Any physician, duly licensed, may use the BOTOX® for any use which he or she deems in the best interest of the patient.
Off-label uses are recognized by the FDA as a normal part of traditional
and mainstream medicine. This is often the way that new uses for existing
medications are discovered.
Because of the enormous cost of conducting the clinical trials and
completing the paperwork necessary to receive a new approved indication
from the FDA, it seems highly unlikely that the manufacturer will
pursue a new approval application at this time. But we are free to
use the drug in our professional capacity as physicians in the best
interest of our patients. The bottom line is that the insurers use
the "off-label" excuse not to reimburse for treatment of
hyperhidrosis. It is not rational, but then neither is the medical
system.
Below are several articles that you can reference for further information:
Schnider P, Binder M, Auff E, Kittler H, Berger T, Wolff K.
Double-blind trial of botulinum A toxin for the treatment of focal
hyperhidrosis of the palms. Br J Dermatol 1997;136:548-52.
Shelley WB, Talanin NY, Shelley ED. Botulinum toxin therapy for palmar
hyperhidrosis. J Am Acad Dermatol 1998;38 (2):227-9.
Naumann M, Hofmann U, Bergmann I, Hamm H, Toyka KV, Reiners K. Focal
Hyperhidrosis. Arch Dermatol 1998;134:301-4.
Glogau, R. Botulinum A Neurotoxin for Axillary Hyperhidrosis: No Sweat
BOTOX® Dermatol Surg 1998; 24:817-819. If you are interested in learning
more about "No Sweat" BOTOX®, please email us or contact
our office for an appointment. Any and all references herein to 'BOTOX®'
refer to 'BOTOX® Purified Neurotoxin Complex', which is a registered
trademark of Allergan. |
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