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BOTOX® for Hyperhidrosis :: Hints & Tips
Treating the axilla
Ask patients which areas bother them to determine how far beyond the hair bearing area to inject. It is also possible to perform an iodine starch test prior to injections to ascertain which areas need to be injected.
The iodine solution is applied to the affected area and then covered with starch. The areas that produce sweat will turn black, telling the physician which areas to inject.
Step 1 - Cover the area to be evaluated with 1 part castor oil and 9 parts iodine.
Use a cotton tipped applicator to apply the red solution to the area to be
evaluated.
Step 2 - Sprinkle the area with potato starch as shown. The areas where
sweating is occurring will turn black. These are the areas that need to be
injected with the botulinum toxin.
Step 3 - The areas of active sweating turn black.
Although this test is messy, it is a useful technique for evaluating the efficacy of the injections and for determining which areas to inject.
Using nerve blocks for pain control
Nerve blocks are a relatively safe method to decrease the pain associated with multiple botulinum injections into the hands and feet. After performing nerve block, the physician should wait 30 minutes for the anesthesia to take effect. It is recommended to give patients a separate informed consent form to sign prior to receiving a nerve block. In addition, patients should be told not to drive for 3 hours after the nerve block and warned that their hands and feet may be clumsy for a few hours until the anesthetic wears off.
U: Ulnar nerve
M: Medial Nerve
R: Radial nerve
- Palmar block: The nerve block is performed with 1% or 2% lidocaine that is injected into the vicinity of the 3 nerves innervating the effected area: the ulnar, radial and medial nerves. The injections are performed thirty minutes before the botulinum toxin treatment. The risks of this procedure can be reduced by avoiding direct injection into the nerve (if paresthesias are felt, one should withdraw a little). In addition, the physician should be careful to avoid intra-arterial injection of the lidocaine.
- Radial nerve block: Subcutaneously inject a wheal of the anesthetic moving anteriorly to posteriorly on the lateral aspect of the wrist at the level of the wrist crease.
- Median nerve block: Have the patient flex the wrist. The needle is inserted between the palmaris longus tendon and the flexor carpi radialis tendon at proximal flexion crease of the wrist.
- Ulnar nerve block: The needle is inserted between the ulnar artery and the flexor carpi ulnaris tendon.
At each of these sites, 3 - 5 cc of anesthesia is slowly injected as the needle is withdrawn.
- Sole block: The nerve block is performed with 1% or 2% lidocaine that is injected into the vicinity of the posterior tibial nerve and the sural nerve.
- Tibial nerve block: The posterior tibial nerve is blocked by introducing the needle at the level of the superior border of the medial malleolus, posterior to the pulse of the posterior tibial artery. The injection is given midway between the posterior tibial artery and the Achilles tendon.
- Sural nerve block: The needle is inserted between the Achilles tendon and the superior border of the lateral malleolus and directing it perpendicular to skin. Six to seven cc of lidocaine are injected in a fanning technique to partially fill the groove between the lateral malleolus and the calcaneus bone.
Side effects: Neuropathy (uncommon), bruising, poor coordination for several hours in area that was anestetized.
References: (For more information and photographs illustrating the injection sites)
- Fujita M, Mann T, Mann O, Berg D. Surgical pearl: use of nerve blocks for botulinum toxin treatment of palmar-plantar hyperhidrosis. J Am Acad Dermatol 2001 Oct;45(4):587-9
- de Almeida AR, Kadunc BV, de Oliveira EM. Improving botulinum toxin therapy for palmar hyperhidrosis: wrist block and technical considerations. Dermatol Surg. 2001 Jan;27(1):34-6.
- Ramamurthy S, Hickey R. Anesthesia: ulnar and median nerve block. In: Green DP, ed. Operative hand surgery. New York: Churchill Livingstone, 1993:37-9.
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