No Compensatory Sweating after Botulinum Toxin Treatment of Palmar Hyperhidrosis
Krogstad AL, et al. British Journal of Dermatology. 2005;152:329-333.
The authors present a trial to determine if treating palmar hyperhidrosis with botulinum A toxin results in compensatory sweating in other body areas. Compensatory sweating has been observed in patients with hyperhidrosis treated with transthoracic endoscopic sympathectomy. Seventeen patients with palmar hyperhidrosis were enrolled and underwent botulinum A toxin injections in their palms. Injections were standardized using a plastic sheet with perforations through which black ink dots were placed, forming a grid. There were 75 to 80 injections per hand. On average, 230 units of toxin were used for the right hand and 237 units were used for the left hand. All patients were treated by the same physician. The degree of sweating was evaluated by measuring water evaporation using a handheld dual probe system. The hands, feet, forehead, breast, abdomen, legs, axillae, and forearms were evaluated. Six measurements were made, 2 before treatment and the remaining 4 at various time points from treatment to 6 months afterward. Patients also subjectively evaluated sweating of the palms and feet using a 10-point scale. All patients reached a statistically significant reduction in water evaporation of their palms. Sweating gradually increased after treatment; however, at 6 months time, a significant difference was still noted compared to pretreatment values. This was also true for the subjective evaluation of sweating by the patients. None of the untreated body locations measured a statistically significant increase in water evaporation after treatment with botulinum A toxin.
This was a relatively small study, but provided good data regarding the efficacy of botulinum A toxin for palmar hyperhidrosis. Statistically significant differences between pre- and post-treatment values of water evaporation were noted up to 6 months after treatment. This was reinforced by the patients' subjective evaluations of sweating. As noted above, patients with palmar hyperhidrosis have been treated with transthoracic endoscopic sympathectomy. During this procedure, a pneumothorax is created in the patient and then a thoracoscope is inserted into the pleural space. (1) The sympathetic trunk is then electrically resected as the scope contains a suction coagulation probe, grasping forceps, and a wire electrode. (1) Patients treated with this procedure have experienced sweating in new body areas, a phenomenon known as compensatory hyperhidrosis. In a systematic review of the literature, Furlan et al found that roughly 50% of patients undergoing either open or transthoracic sympathectomy experienced compensatory hyperhidrosis and that 25% of these patients considered it to be worse than their initial disease or disabling. (2) This treatment also has associated complications relating to the disruption of sympathetic nerves such as transient or permanent Horner's syndrome and neuralgic pains, not to mention the complications related to the surgical procedure. (2) This study demonstrates the safety, efficacy, and lack of side effects when treating palmar hyperhidrosis with botulinum A toxin and establishes a role for dermatologists in treating this condition.
1. Kux M. Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis. Arch Surg. 1978; 113(3):264-6.
2. Furlan AD, et al. Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications. The Journal of Pain. 2000;1(4):245-257.
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