1400
Correspondence
such as burns and trauma, which occur secondary to sensory impairment. Aya Kobayashi, MD Hisashi Uhara, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan Kenji Kido, MD, PhD Division of Dermatology Shinonoi General Hospital Nagano Japan Yoshiki Sekijima, MD, PhD Kana Tojo, MD, PhD Shu-ichi Ikeda, MD, PhD Department of Neurology Shinshu University School of Medicine Matsumoto Japan
Modified protocol for the application of botulinum toxin type A for hyperhidrosis of the nose
Editor, We refer to an article published in this journal in 2008 by Geddoa et al.1 on the treatment of nasal hyperhidrosis with botulinum toxin type A and wish to propose some factors that should be considered with reference to the level of comfort experienced by the patient. Because the nose does not represent a large area of skin and as injections in this area are extremely painful, we have identified some methods of improving the technique described in 2008.1 Botulinum toxin type A can be applied via injections to sites separated by distances of 2 cm to provide total control of hyperhidrosis.2 Thus, given this distance of 2 cm between injection sites, there is generally no need to make more than nine injections into the nose (Fig. 1), rather than the 20 described in the earlier article.1 This eliminates the need for 11 painful injections. Another valuable technique for controlling pain, which has already been explored, involves the use of a skin-cooling device before injection.3,4 A recent review of strategies for reducing pain in botulinum toxin applications recommended the use of a eutectic mixture of local anesthetics (EMLA) and advised that the toxin should be diluted with sterile saline-containing preservative (benzyl alcohol) rather than sterile distilled water as the latter enhances pain.5 Another method of reducing pain involves vibration anesthesia.6 Comparisons between the methods are complicated International Journal of Dermatology 2013, 52, 1398–1461
Ryuhei Okuyama, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan E-mail: [email protected]
References 1 Andrade C. A peculiar form of peripheral neuropathy; familiar atypical generalized amyloidosis with special involvement of the peripheral nerves. Brain 1952; 75: 408–427. 2 Hund E, Linke RP, Willig F, et al. Transthyretinassociated neuropathic amyloidosis. Pathogenesis and treatment. Neurology 2001; 56: 431–435. 3 Rocha N, Velho G, Horta M, et al. Cutaneous manifestations of familial amyloidotic polyneuropathy. J Eur Acad Dermatol Venereol 2005; 19: 605–607. 4 Rubinow A, Cohen AS. Skin involvement in familial amyloidotic polyneuropathy. Neurology 1981; 31: 1341–1345.
because various different vibration and cooling devices are available. Some risks exist with cooling devices if the period of application or temperature of the device exceeds the threshold of tolerance.
Figure 1 Sites of application of botulinum toxin type A to
the nose
ª 2013 The International Society of Dermatology
Correspondence
We used this modified protocol to treat two patients with Botox (Allergan, Inc., Irvine, CA, USA). The first patient continues to show good results at six months. The second patient also shows good results but represents a more recent case, and only data for follow-up at three months are available. These patients felt almost no discomfort at the application of the toxin after the use of a cooling device. In these cases, we used an ice roller, a common device used to minimize pain in laser and botulinum toxin applications. We used two units of botulinum toxin type A at each site of intradermal injection. Doses used for injections to the nose can vary. A small study has shown higher doses in the axilla to have prolonged effects.7 In order to enhance the comfort of patients, we propose the use of cold probes and injection with botulinum toxin type A at nine points only for the treatment of nasal hyperhidrosis. It is possible that EMLA in combination with skin cooling may work better in sensitive patients, but the effects of this combination need to be evaluated in further studies. Juliano de Avelar Breunig, MD, PhD Department of Dermatology Faculty of Medicine Santa Cruz do Sul University Santa Cruz do Sul Brazil E-mail: [email protected] Rodrigo Pereira Duquia, MD Department of Postgraduate Dermatology Pontifical Catholic University of Rio Grande do Sul Porto Alegre Brazil Faculty of Medicine Federal University of Pelotas Pelotas Brazil
Postoperative pathergic pyoderma gangrenosum after aortic aneurysm repair
Editor, A 72-year-old man was admitted to New York University Medical Center for repair of a thoracoabdominal aortic aneurysm. His past medical history included peripheral vascular disease, type 2 diabetes mellitus, multiple strokes, and hypertension. The patient underwent an aortobifemoral bypass graft to repair the suprarenal thoracoabdominal aortic aneurysm. His postoperative course was complicated by the development of fever and leukocytosis of unclear etiology. On postoperative ª 2013 The International Society of Dermatology
Hiram de Almeida Jr, MD, PhD Department of Postgraduate Dermatology Pontifical Catholic University of Rio Grande do Sul Porto Alegre Brazil Faculty of Medicine Federal University of Pelotas Pelotas Brazil Faculty of Medicine Catholic University of Pelotas Pelotas Brazil References 1 Geddoa E, Balakumar AK, Paes TR. The successful use of botulinum toxin for the treatment of nasal hyperhidrosis. Int J Dermatol 2008; 47: 1079–1080. 2 Heckmann M, Breit S, Ceballos-Baumann A, et al. Sidecontrolled intradermal injection of botulinum toxin A in recalcitrant axillary hyperhidrosis. J Am Acad Dermatol 1999; 41: 987–990. 3 Linder JS, Edmonson BC, Laquis SJ, et al. Skin cooling before periocular botulinum toxin A injection. Ophthal Plast Reconstr Surg 2002; 18: 441–442. 4 Sarifakioglu N, Sarifakioglu E. Evaluating the effects of ice application on the pain felt during botulinum toxin type A injections: a prospective, randomized, single-blind controlled trial. Ann Plast Surg 2004; 53: 543–546. 5 Azzopardi EA, Whitaker IS. Acute pain management during facial injection of botulinum toxin: an evidence-based systematic review. Plast Reconstr Surg 2010; 125: 162–164. 6 Smith KC, Comite SL, Balasubramanian S, et al. Vibration anesthesia: a non-invasive method of reducing discomfort prior to dermatologic procedures. Dermatol Online J 2004; 10: 1–2. 7 Wollina U, Karamfilov T, Konrad H. High-dose botulinum toxin type A therapy for axillary hyperhidrosis markedly prolongs the relapse-free interval. J Am Acad Dermatol 2002; 46: 536–540.
day 5, new skin lesions began to develop at the sites of surgical incision. All wound cultures and gram stains performed by the primary team were negative. A wound infection was still suspected, and the patient was treated with broad-spectrum antibiotics without clinical improvement. Physical examination demonstrated bullous and purpuric arciform plaques with fibrinous exudate localized to incision sites on the left upper chest, abdomen, and groin (Fig. 1). No other lesions were observed. Because the lesions were both well defined and located adjacent to incision sites only, a postoperative neutrophilic International Journal of Dermatology 2013, 52, 1398–1461
1401
Correspondence
such as burns and trauma, which occur secondary to sensory impairment. Aya Kobayashi, MD Hisashi Uhara, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan Kenji Kido, MD, PhD Division of Dermatology Shinonoi General Hospital Nagano Japan Yoshiki Sekijima, MD, PhD Kana Tojo, MD, PhD Shu-ichi Ikeda, MD, PhD Department of Neurology Shinshu University School of Medicine Matsumoto Japan
Modified protocol for the application of botulinum toxin type A for hyperhidrosis of the nose
Editor, We refer to an article published in this journal in 2008 by Geddoa et al.1 on the treatment of nasal hyperhidrosis with botulinum toxin type A and wish to propose some factors that should be considered with reference to the level of comfort experienced by the patient. Because the nose does not represent a large area of skin and as injections in this area are extremely painful, we have identified some methods of improving the technique described in 2008.1 Botulinum toxin type A can be applied via injections to sites separated by distances of 2 cm to provide total control of hyperhidrosis.2 Thus, given this distance of 2 cm between injection sites, there is generally no need to make more than nine injections into the nose (Fig. 1), rather than the 20 described in the earlier article.1 This eliminates the need for 11 painful injections. Another valuable technique for controlling pain, which has already been explored, involves the use of a skin-cooling device before injection.3,4 A recent review of strategies for reducing pain in botulinum toxin applications recommended the use of a eutectic mixture of local anesthetics (EMLA) and advised that the toxin should be diluted with sterile saline-containing preservative (benzyl alcohol) rather than sterile distilled water as the latter enhances pain.5 Another method of reducing pain involves vibration anesthesia.6 Comparisons between the methods are complicated International Journal of Dermatology 2013, 52, 1398–1461
Ryuhei Okuyama, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan E-mail: [email protected]
References 1 Andrade C. A peculiar form of peripheral neuropathy; familiar atypical generalized amyloidosis with special involvement of the peripheral nerves. Brain 1952; 75: 408–427. 2 Hund E, Linke RP, Willig F, et al. Transthyretinassociated neuropathic amyloidosis. Pathogenesis and treatment. Neurology 2001; 56: 431–435. 3 Rocha N, Velho G, Horta M, et al. Cutaneous manifestations of familial amyloidotic polyneuropathy. J Eur Acad Dermatol Venereol 2005; 19: 605–607. 4 Rubinow A, Cohen AS. Skin involvement in familial amyloidotic polyneuropathy. Neurology 1981; 31: 1341–1345.
because various different vibration and cooling devices are available. Some risks exist with cooling devices if the period of application or temperature of the device exceeds the threshold of tolerance.
Figure 1 Sites of application of botulinum toxin type A to
the nose
ª 2013 The International Society of Dermatology
Correspondence
We used this modified protocol to treat two patients with Botox (Allergan, Inc., Irvine, CA, USA). The first patient continues to show good results at six months. The second patient also shows good results but represents a more recent case, and only data for follow-up at three months are available. These patients felt almost no discomfort at the application of the toxin after the use of a cooling device. In these cases, we used an ice roller, a common device used to minimize pain in laser and botulinum toxin applications. We used two units of botulinum toxin type A at each site of intradermal injection. Doses used for injections to the nose can vary. A small study has shown higher doses in the axilla to have prolonged effects.7 In order to enhance the comfort of patients, we propose the use of cold probes and injection with botulinum toxin type A at nine points only for the treatment of nasal hyperhidrosis. It is possible that EMLA in combination with skin cooling may work better in sensitive patients, but the effects of this combination need to be evaluated in further studies. Juliano de Avelar Breunig, MD, PhD Department of Dermatology Faculty of Medicine Santa Cruz do Sul University Santa Cruz do Sul Brazil E-mail: [email protected] Rodrigo Pereira Duquia, MD Department of Postgraduate Dermatology Pontifical Catholic University of Rio Grande do Sul Porto Alegre Brazil Faculty of Medicine Federal University of Pelotas Pelotas Brazil
Postoperative pathergic pyoderma gangrenosum after aortic aneurysm repair
Editor, A 72-year-old man was admitted to New York University Medical Center for repair of a thoracoabdominal aortic aneurysm. His past medical history included peripheral vascular disease, type 2 diabetes mellitus, multiple strokes, and hypertension. The patient underwent an aortobifemoral bypass graft to repair the suprarenal thoracoabdominal aortic aneurysm. His postoperative course was complicated by the development of fever and leukocytosis of unclear etiology. On postoperative ª 2013 The International Society of Dermatology
Hiram de Almeida Jr, MD, PhD Department of Postgraduate Dermatology Pontifical Catholic University of Rio Grande do Sul Porto Alegre Brazil Faculty of Medicine Federal University of Pelotas Pelotas Brazil Faculty of Medicine Catholic University of Pelotas Pelotas Brazil References 1 Geddoa E, Balakumar AK, Paes TR. The successful use of botulinum toxin for the treatment of nasal hyperhidrosis. Int J Dermatol 2008; 47: 1079–1080. 2 Heckmann M, Breit S, Ceballos-Baumann A, et al. Sidecontrolled intradermal injection of botulinum toxin A in recalcitrant axillary hyperhidrosis. J Am Acad Dermatol 1999; 41: 987–990. 3 Linder JS, Edmonson BC, Laquis SJ, et al. Skin cooling before periocular botulinum toxin A injection. Ophthal Plast Reconstr Surg 2002; 18: 441–442. 4 Sarifakioglu N, Sarifakioglu E. Evaluating the effects of ice application on the pain felt during botulinum toxin type A injections: a prospective, randomized, single-blind controlled trial. Ann Plast Surg 2004; 53: 543–546. 5 Azzopardi EA, Whitaker IS. Acute pain management during facial injection of botulinum toxin: an evidence-based systematic review. Plast Reconstr Surg 2010; 125: 162–164. 6 Smith KC, Comite SL, Balasubramanian S, et al. Vibration anesthesia: a non-invasive method of reducing discomfort prior to dermatologic procedures. Dermatol Online J 2004; 10: 1–2. 7 Wollina U, Karamfilov T, Konrad H. High-dose botulinum toxin type A therapy for axillary hyperhidrosis markedly prolongs the relapse-free interval. J Am Acad Dermatol 2002; 46: 536–540.
day 5, new skin lesions began to develop at the sites of surgical incision. All wound cultures and gram stains performed by the primary team were negative. A wound infection was still suspected, and the patient was treated with broad-spectrum antibiotics without clinical improvement. Physical examination demonstrated bullous and purpuric arciform plaques with fibrinous exudate localized to incision sites on the left upper chest, abdomen, and groin (Fig. 1). No other lesions were observed. Because the lesions were both well defined and located adjacent to incision sites only, a postoperative neutrophilic International Journal of Dermatology 2013, 52, 1398–1461
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