BOTULINUM TOXIN in .NET

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CHAPTER 22 BOTULINUM TOXIN
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INGUINAL HYPERHIDROSIS
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Inguinal hyperhidrosis (IH) is a focal and primary form of hyperhidrosis in which the individual has intense sweating in
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FIGURE 22-24 Wrinkling of the nasalis muscle or bunny lines leads to medical wrinkling under the eyes
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FIGURE 22-25 Injection site to treat bunny lines
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lation of the lingual nerves The decreased salivation was temporary, and did not appear to be directly toxic to the acinar cells of the gland74 Canine studies have also shown that vasomotor rhinorrhea, a parasympathetically controlled phenomenon, responds favorably to topical BTX-A While the duration of action of BTX-A at the neuromuscular junction appears to be approximately 3 months, a longer-lasting effect may occur at the glandular level BTX-A has produced anhydrosis for more than 12 months in patients with gustatory sweating The reason for the difference in duration of action is uncertain; hypotheses include a higher rate of resynthesis of SNAP-25 (the protein cleaved by BTX) in neuromuscular synapses, and a higher area of axonal sprouting and consecutive reinnervation of muscle fibers as compared to that in glandular tissue75,76 rences of the hyperhidrosis72 Gustatory sweating is another area of neuroglandular dysfunction in which BTX-A has proven effective Gustatory sweating (or Frey s syndrome) is a disabling disorder in which the cheek skin sweats profusely during eating The syndrome may occur after parotidectomy, and is likely due to the misdirection of regenerating parasympathetic fibers that innervate the sweat glands of the face Intracutaneous BTX-A has been reported to significantly decrease or prevent sweating for more than 6 months, with no clinical evidence of facial weakness in any patients73 BTXA injected into the submandibular glands has been reported to significantly decrease salivation resulting from stimu-
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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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the inguinal region Appearing in adolescence, usually not later than the age of 25, the condition continues into adulthood IH is characterized by chronic, intense sweating in the inguinal region, a situation that is potentially embarrassing for the patient IH symmetrically affects the groin region, including the suprapubic area, the shallow depression that lies immediately below the fold of the groin (corresponding to the femoral triangle), the medial surfaces of the upper inner thighs, and the genital area It may also include the lower part of the gluteus maximus, gluteal fold, and natal cleft69 No study to date has described the ideal doses of BTX for the treatment of IH The threshold doses of BTX-A for the treatment of hyperhidrosis depend on the severity of the condition70 Two or three units of BTX-A per square centimeter can be used to treat the hyperhidrotic area in the inguinal region The only side effects reported in the sparse literature are those related to the injections, such as rare small hematomas and temporary edema71
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PAIN CONTROL
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With the expanding use of botulinum toxins in cosmetic practice, pain alleviation remains an important aspect of the injection Pain sensation is dependent on many factors, most importantly the concentration of the neuropeptides (substance P) at the site of injection, the tissue density (higher tissue density implies more pain), and the density of the nociceptor distribution at the site of injection Other factors include the volume injected, the bore of the needle used, the layer of skin within which the toxin is injected, the rate of the fluid injection, and, of course, the physician s level of experience77
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OTHER NEUROGLANDULAR DISORDERS
The effects of BTX-A at the neuroglandular junction have not been explored as extensively as those occurring at the neuromuscular junction Clinical studies examining the effect of intracutaneous BTX for focal hyperhidrosis found complete abolition of sweating in the injected area within 3 to 7 days No adverse effects were reported, and in a 5-month follow-up there were no clinical recur-
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