Get rid of hyperhidrosis
After it be approved for various other purposes since 1989, inclusive to improve the frown lines appearance among the eyebrows, Botox now can treat to sweat severe of armpit (hyperhidrosis primary of axillary therefore cannot be handled for trite agents.
Botox (toxin of toxin botulínica types A glycopyrrolate hyperhidrosis) is a protein produced by the toxin botulínica of the get rid of hyperhidrosis bacteria Clostridium. Treating when is used to sweat of armpit, small dose injected of the sterile liberation purified of the toxin toxin stop botulínica of the acetylcholine chemical of messenger, blocking temporarily the nerves in the armpit that stimulates to sweat. Hyperhidrosis primary of axillary is a medical condition characterized by sweating excessive of armpit that is thought to result of the hyperstimulation located of glands sudaríparas by cholinergic nice fibers of nerve. It can be associated with emotional, physical, professional, and significant deterioration as well as considerable difficulties in social situations and in personal relations. The available therapies have been limited for the efficacy and the at times significant adverse ephemeral effects that can put patients in the risk for potentially serious complications. Chemodenervation of glands sudaríparas that utilizes toxin of toxin botulínica types A (BTX-A), that has the most minimum adverse effective lasting therapeutic efficacy, has arisen like an extraordinary therapy to treat hyperhidrosis primary of axillary. This article revises the procedure of chemodenervation, inclusive the patient preparation, the administration of BTX-A, and glycopyrrolate hyperhidrosis get rid of hyperhidrosis the evaluation and patient monitoring.
Hyperhidrosis primary of axillary is a pathological condition characterized by sweating excessive of armpit. While the exact cause is not known, is thought to result of the hyperstimulation of glands of eccrine by the cholinergic nice fibers of nerve that innervate they. The etiology of hyperhidrosis primary appears also to have a genetic component, like the frequency of the history of the family of patient-reported is consistent with autosomal the dominant broadcast (1). The beginning of hyperhidrosis of axillary is typically in adolescence (2) or young adult age (3), and its frequency is higher in the flower that works years (ages 18-64 years) (3).
On account of the intensity of its symptoms, hyperhidrosis primary of axillary can have as a result significant deterioration in both professional and personal activities and is associated with the quality substantially reduced of the life (4-7). Sweating excessive can have as a result still more maceration of skin and can be associated with secondary microbic infections in people severely affected. The disturbance emotional associate with hyperhidrosis can be amplified for the persistence of the humidity, to stain, and of the damage to the clothes (8). Coherent with these observations, the load of the quality of the life with hyperhidrosis primary of axillary is comparable to or worse than that observed in patients with the acné severe, with pruritus, or with the soriasis (4).
The data published indicate that the frequency of hyperhidrosis primary is between 0,6% and 2,8% (3,9,10). The data in the frequency of hyperhidrosis by the focal severity of the location and the symptom they are examined. Nevertheless, a recent study reckoned that 0,5% of the population of US is sorrowful with hyperhidrosis severe of axillary, defined sweating as that is barely tolerable or intolerable and that frequently or always get rid of hyperhidrosis intervenes with the daily activities of person (3).
Hyperhidrosis primary of axillary dealt with several therapies, traveling through of trite agents to oral medicines sistémicas to the sympathectomy surgical. The successful processing of hyperhidrosis has as a result the substantial improvements in functioning of patient and quality of the life (11). Nevertheless, the available glycopyrrolate hyperhidrosis processing have been limited for one or by various factors, inclusive ephemeral effects (12.13) and to sweat compensatory substantial (13-15), as well as tolerability poor (16) and the potentially serious complications (just as syndrome of pneumothorax or Horner) (13-15,17).
Chemodenervation that utilizes toxin of toxin botulínica types A (BTX-A) has arisen like a sure processing and cash for the hyperhidrosis primary of axillary. This procedure has been utilized also extensively for the processing of the strabismus, blepharospasm, and the headache and neck they associated with dystonia cervical. Toxin of toxin botulínica types AN acts blocking the liberation neuronal of acetylcholine in the junction of neuromuscular and in the cholinergic the autonomous neurons (18). When did it administer in excessive places to sweat, the products of BTX-A denervation temporary of the glands sudaríparas, having as a result the local reduction to sweat (2).
The studies controlled randomized carried out in Europe and the United Kingdom show that chemodenervation of glands sudaríparas with BTX-A has as a result the substantial and fast reductions in sweating of axillary, as quantified by the measure gravimétrica of the production of the sweat (6,19,20). These conclusions have been confirmed recently and they have been extended in an American study of 52 weeks that shows that chemodenervation that utilizes BTX-A reduces dramatically the production of the sweat of axillary and improves notably the associated deterioration with hyperhidrosis (21). The primary point of the end of the efficacy in this double-blind one the trial placebo-controlled was the Scale of the Severity of the Illness of Hyperhidrosis (HDSS), a psychometrically validated alone-article the scale of 4 points in which patient they value how hyperhidrosis intervenes glycopyrrolate hyperhidrosis with its daily activities and its tolerability perceived get rid of hyperhidrosis (22) (Postpones 1). The ninety percent of the patients reported that after the processing that its hyperhidrosis was not tolerable neither notable and, in worse, only at times intervened with its daily activities. Besides, more than 80% of patients dealt with BTX-A showed a 75% or the largest reduction to sweat, measured gravimétricamente. The majority of the effects of the side of the processing of BTX-A was temperate and transitory.
This article revises the procedures and better clinical practices to treat hyperhidrosis primary of axillary by chemodenervation of glands sudaríparas that utilize BTX-A.
Procedure of Chemodenervation
Both axillae is tried generally in the same visit of the office. There can be the considerable variation of the patient to the patient in the excessive area to sweat inside the camera of axillary. In some patients, is limited to the skin of the hair-bearing and in the other that extends it beyond this area. Besides, the excessive areas to sweat can vary in the same patient. On account of this buries- and the changeability of intrapatient, drawing the excessive area of sweating is a first very important step in the procedure of chemodenervation.
The first step in the cartography of the area of hyperhidrotic is to carry out the test of the iodine-starch of Smaller, which marks direct mental image of the possible area. Specifically, the axillae is cleaned first and is dried completely. The area then is painted with a solution of the iodine (2 G of the iodine in 10 ML of almond oil or castor oil and of 90 ML of alcohol). An alternative one is to utilize the povidone-iodine with alcohol (p.and., Betadine) cotton. After the solution have dried, fine dust of starch is removed the dust evenly on the place. After various minutes, the presence of the causes of the sweat that the mixture to rotate a dark blue purple color, doing glycopyrrolate hyperhidrosis the location of the to sweat easily discernible. The areas of hyperhidrotic then are summarized with a surgical one or feather of dermographic and they are reprepped with the solution antibacterial.
The reconstitución and dosing of BTX-A
Empty-dried purified BTX-A (BOTOX [R], Allergan, Irvine , Calif ; 100 OR by flask) is reconstituido with 4 ML of sterile 0,9% of saline solution (25 OR/ML). The total volume of the injection (4 ML) then is drawn in 4 separated 1 syringes of ML with a 20- to the needle of 22 calipers. To reduce the patient inconvenience, the needle should be replaced with a higher caliper (p.and., of 30 calipers) the needle before injection. By the it has as a result the clinical studies, the dose recommended is 50 OR/axilla (6,20,21). The recent data indicate that there is not the significant differences in the efficacy neither the duration of the effect among dose of 50 OR/axilla and of 75 OR/axilla (21). Some doctors have suggested that processing of highly-dose (200 OR/axilla) can be associated with a more long duration of the effect (23); nevertheless, this study was not preliminary and well controlled. Since the dose of 50 OR/axilla is extremely effective, well tolerated, and is associated with a lasting effect (6 to 7 months) (6.24) clinical should opt for it in the majority of the patients. When it shown on the table 2, the volume of injection varies according to the number of the places that have been layout, and 12 to 15 places are typical in a patient media. Approximately 0,13 ML of BTX-AN is given for injection when there is 15 places separated of injection in the area of hyperhidrotic of the axilla.
Administration of BTX-A
Since each place of the processing has a ring of the effect of approximately 2 cm of diameter, the points of injection should be spaced evenly 1,5 cm aside and they are marked before advancing. To reduce the area of no effect, the places should be positioned in a way staggered before that in a lineal fashion (Figure 1). Alternative, the area can be divided into square 1.5-cm, with the place of injection in the center of each square (5). BTX-AN is injected slowly and with care in the airplane get rid of hyperhidrosis of intradermal of each axilla. The doctor should try to obtain a wheal visible that confirms the placement of the drug in the appropriate airplane of the skin. Pressure then should be applied to facilitate hemostasis. After the processing, the areas of hyperhidrotic are cleaned and the patient is observed for sideways potential effects for approximately 20 minutes.
They to be tried before to sweat of armpit, the patients should be evaluated for other potential causes of the problem. The events more common adverse associated with the new processing the pain included of the place of injection and hemorrhage, sweating in other parts of the body, of the symptoms of flu-wants, of the headache, of the fever, of stinging, and of the anxiety..
Botox was approved first in December 1989 in treating the blepharospasm of eye muscle disorders and strabismus. Since then, has been approved to treat a neurological disorder of the movement that glycopyrrolate hyperhidrosis causes severe neck and shoulder muscle contractions (dystonia cervical). In 2002, it was approved as Cosmetic of Botox to improve the lines of the frown.
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