LETTERS AND COMMUNICATIONS
Botulinum Toxin A for Palmar Hyperhidrosis: Associated Pain, Duration, and Reasons for Discontinuation of Therapy Primary focal hyperhidrosis (HH) is a chronic disease characterized by excessive sweating in localized areas of the body including axillae, palms, soles, and face. Prevalence of HH is 2.8% in the United States. 1 Behind axillae, palms are the second most common area of involvement.2 Initial therapies such as topical antiperspirants and iontophoresis are not effective in all patients with palmar HH. Second-line treatment includes botulinum toxin type A (BTX-A) injections, which can be very effective for palmar HH.3 Methods of pain control include cold anesthesia, topical anesthetics, vibration, and nerve blocks.4 To date, however, studies lack general agreement regarding the dosing and duration of BTX-A for palmar HH as well as methods of optimal pain control. The authors conducted an institutional review board–approved retrospective chart review to investigate the duration of effect and pain associated with BTX-A injections for the treatment of palmar HH. Data were collected from electronic medical records of patients who were seen at Saint Louis University Department of Dermatology (SLU) HH clinic with the diagnosis of primary focal HH between February 1, 2011, and January 1, 2014 (Figure 1). A total of 749 patients’ charts with primary focal HH were reviewed, and of these patients, 379 patients (51%) had palmar involvement. Of the patients with palmar HH, 21 were treated with BTX-A. Previous treatments for these patients included prescription-strength topical antiperspirants (17 patients; 85%), oral anticholinergic agents (14 patients; 70%), and iontophoresis (8 patients; 40%). Default method of pain control for BTX-A treatments at SLU is the use of ice with pressure. Patients received 2.5 mouse units (U) of onabotulinumtoxinA (Allergan, Inc., Irvine, CA) spaced approximately 1 cm apart, for an average of 75 to 100 injections and 100 to 150 U per hand. Patients
were asked to rate the pain of procedure on a scale of 1 to 10, 1 being no pain and 10 being most severe pain. The mean and median patient-reported pain score was 3.4 and 3.0, respectively (range, 1–6). The mean and median duration of BTX-A effect reported was 6.6 months and 6.0 months, respectively (range, 2–23 months). In data analysis, 12 patients had discontinued BTX-A injections. Six patients reported insurance coverage as the sole reason for discontinuation of BTX-A. Five patients reported other reasons including unacceptable hand weakness (n = 2), pain (n = 1), inadequate improvement (n = 1), and concern for excessive bleeding in a patient who began taking warfarin (n = 1). One patient was lost to follow-up. The authors conclude from this study that BTX-A injections for the treatment of palmar HH is well tolerated and that pain is not a major barrier to
Figure 1. Patient disposition.
41:2:FEBRUARY 2015
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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LETTERS AND COMMUNICATIONS
care. Interestingly, only 1 of 21 patients (4.8%) reported pain (pain score 5/10) as the reason for discontinuation of BTX-A. Pain is well controlled using ice with pressure during the procedure, and it does not prevent patients from returning for continued management with BTX-A. Instead, insurance exclusion of BTX-A and high costs seem to be the major contributing factors for the cessation of treatment. References 1. Strutton D, Kowalski J, Glaser D, Stang P. U.S. prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004;51:241–8. 2. Lear W, Kessler E, Solish N, Glaser D. An epidemiological study of hyperhidrosis. Dermatol Surg 2007;33:S69–75.
3. Solomon B, Hayman R. Botulinum toxin type a therapy for palmar and digital hyperhidrosis. J Am Acad Dermatol 2000;42:1026–9. 4. Glaser D, Hebert A, Pariser D, Solish N. Palmar and plantar hyperhidrosis: best practice recommendations and special considerations. Cutis 2007;79(Suppl l):18–28.
Alison Kang, BA Erin Burns, MD Dee Anna Glaser, MD Department of Dermatology Saint Louis University School of Medicine St. Louis, Missouri Dr. Dee Anna Glaser is a consultant and investigator for Allergan, Inc. Alison Kang and Dr. Erin Burns have no conflicts of interest.
Primary Varicose Vein of the Upper Limb
Primary varicose veins (VVs) of the upper limb are very rare with only few reports in the last decades. In this article, a case of symptomatic primitive VV of the left upper limb is reported including diagnosis and treatment. This 63-year-old woman presented with a 2-year history of a VV on the left arm progressively increased in caliber and extension (Figure 1A). In the last weeks, the VV was associated with pain and heavy feeling. Symptoms and vein turgidity worsened during the hotter hours of the day and sun exposure. Duplex demonstrated a varicose epifascial vein running obliquely in the superficial hypodermis of the anteromedial face of the arm. This VV connected the basilic with the cephalic veins, which appeared normal in size (Figure 2). Duplex excluded anatomic or hemodynamic abnormalities in the deep and the other superficial veins, at rest and during maneuvers testing for venous thoracic outlet syndrome (vTOS). Occlusive compression of the subclavian and axillary veins and vascular malformations were excluded by dynamic CT venography. No other VV could be observed in other territories. Under local anesthesia, the connection with the basilic vein was isolated and ligated with Vicryl 3-0.
298
Then, multiple phlebectomies were performed up to the margin of the deltoid muscle. The proximal end of the VV was ligated. A graduated compression arm sleeve was applied for 10 days. No complications were observed (Figure 1B). Two years later, an excellent functional and cosmetic result was observed with no recurrence.
Figure 1. (A) The left arm at admission. (B) 3D-CT showing the epifascial path of the VV (arm elevated). (C) 3D-CT showing the connection of the VV with the cephalic and basilica veins (arm elevated). (D) The left arm, 10 days after operation.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Botulinum Toxin A for Palmar Hyperhidrosis: Associated Pain, Duration, and Reasons for Discontinuation of Therapy Primary focal hyperhidrosis (HH) is a chronic disease characterized by excessive sweating in localized areas of the body including axillae, palms, soles, and face. Prevalence of HH is 2.8% in the United States. 1 Behind axillae, palms are the second most common area of involvement.2 Initial therapies such as topical antiperspirants and iontophoresis are not effective in all patients with palmar HH. Second-line treatment includes botulinum toxin type A (BTX-A) injections, which can be very effective for palmar HH.3 Methods of pain control include cold anesthesia, topical anesthetics, vibration, and nerve blocks.4 To date, however, studies lack general agreement regarding the dosing and duration of BTX-A for palmar HH as well as methods of optimal pain control. The authors conducted an institutional review board–approved retrospective chart review to investigate the duration of effect and pain associated with BTX-A injections for the treatment of palmar HH. Data were collected from electronic medical records of patients who were seen at Saint Louis University Department of Dermatology (SLU) HH clinic with the diagnosis of primary focal HH between February 1, 2011, and January 1, 2014 (Figure 1). A total of 749 patients’ charts with primary focal HH were reviewed, and of these patients, 379 patients (51%) had palmar involvement. Of the patients with palmar HH, 21 were treated with BTX-A. Previous treatments for these patients included prescription-strength topical antiperspirants (17 patients; 85%), oral anticholinergic agents (14 patients; 70%), and iontophoresis (8 patients; 40%). Default method of pain control for BTX-A treatments at SLU is the use of ice with pressure. Patients received 2.5 mouse units (U) of onabotulinumtoxinA (Allergan, Inc., Irvine, CA) spaced approximately 1 cm apart, for an average of 75 to 100 injections and 100 to 150 U per hand. Patients
were asked to rate the pain of procedure on a scale of 1 to 10, 1 being no pain and 10 being most severe pain. The mean and median patient-reported pain score was 3.4 and 3.0, respectively (range, 1–6). The mean and median duration of BTX-A effect reported was 6.6 months and 6.0 months, respectively (range, 2–23 months). In data analysis, 12 patients had discontinued BTX-A injections. Six patients reported insurance coverage as the sole reason for discontinuation of BTX-A. Five patients reported other reasons including unacceptable hand weakness (n = 2), pain (n = 1), inadequate improvement (n = 1), and concern for excessive bleeding in a patient who began taking warfarin (n = 1). One patient was lost to follow-up. The authors conclude from this study that BTX-A injections for the treatment of palmar HH is well tolerated and that pain is not a major barrier to
Figure 1. Patient disposition.
41:2:FEBRUARY 2015
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
297
LETTERS AND COMMUNICATIONS
care. Interestingly, only 1 of 21 patients (4.8%) reported pain (pain score 5/10) as the reason for discontinuation of BTX-A. Pain is well controlled using ice with pressure during the procedure, and it does not prevent patients from returning for continued management with BTX-A. Instead, insurance exclusion of BTX-A and high costs seem to be the major contributing factors for the cessation of treatment. References 1. Strutton D, Kowalski J, Glaser D, Stang P. U.S. prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004;51:241–8. 2. Lear W, Kessler E, Solish N, Glaser D. An epidemiological study of hyperhidrosis. Dermatol Surg 2007;33:S69–75.
3. Solomon B, Hayman R. Botulinum toxin type a therapy for palmar and digital hyperhidrosis. J Am Acad Dermatol 2000;42:1026–9. 4. Glaser D, Hebert A, Pariser D, Solish N. Palmar and plantar hyperhidrosis: best practice recommendations and special considerations. Cutis 2007;79(Suppl l):18–28.
Alison Kang, BA Erin Burns, MD Dee Anna Glaser, MD Department of Dermatology Saint Louis University School of Medicine St. Louis, Missouri Dr. Dee Anna Glaser is a consultant and investigator for Allergan, Inc. Alison Kang and Dr. Erin Burns have no conflicts of interest.
Primary Varicose Vein of the Upper Limb
Primary varicose veins (VVs) of the upper limb are very rare with only few reports in the last decades. In this article, a case of symptomatic primitive VV of the left upper limb is reported including diagnosis and treatment. This 63-year-old woman presented with a 2-year history of a VV on the left arm progressively increased in caliber and extension (Figure 1A). In the last weeks, the VV was associated with pain and heavy feeling. Symptoms and vein turgidity worsened during the hotter hours of the day and sun exposure. Duplex demonstrated a varicose epifascial vein running obliquely in the superficial hypodermis of the anteromedial face of the arm. This VV connected the basilic with the cephalic veins, which appeared normal in size (Figure 2). Duplex excluded anatomic or hemodynamic abnormalities in the deep and the other superficial veins, at rest and during maneuvers testing for venous thoracic outlet syndrome (vTOS). Occlusive compression of the subclavian and axillary veins and vascular malformations were excluded by dynamic CT venography. No other VV could be observed in other territories. Under local anesthesia, the connection with the basilic vein was isolated and ligated with Vicryl 3-0.
298
Then, multiple phlebectomies were performed up to the margin of the deltoid muscle. The proximal end of the VV was ligated. A graduated compression arm sleeve was applied for 10 days. No complications were observed (Figure 1B). Two years later, an excellent functional and cosmetic result was observed with no recurrence.
Figure 1. (A) The left arm at admission. (B) 3D-CT showing the epifascial path of the VV (arm elevated). (C) 3D-CT showing the connection of the VV with the cephalic and basilica veins (arm elevated). (D) The left arm, 10 days after operation.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
