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Palmar hyperhidrosis: Safety and efficacy of two anaesthetic techniques for botulinum toxin therapy

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Palmar hyperhidrosis. Safety and efficacy of two anesthetic techniques for botulinum toxin therapy
Rosa María Ponce-Olivera1, Andrés Tirado-Sánchez1, María Ivonne Arellano-Mendoza1, Gladys León-Dorantes1, and Silvia Kassian-Rank2
Dermatology Online Journal 12 (2): 9

1. Servicio de Dermatología, Hospital General de México.
2. Servicio de Medicina del Dolor, Hospital General de México


Palmar hyperhidrosis (PH) is a condition that can lead to psychological problems that affects quality of life [1]. Topical and systemic treatment are not entirely effective in all patients. Botulinum toxin type A (BTX-A) is a highly effective treatment for focal hyperhidrosis, including PH, however, the intradermal injections are commonly painful for the patient [2].

Topical anesthetics have been used with poor response [3]. Peripheral nerve blockade may be useful for this purpose. Intravenous regional anesthesia or Bier's block has been used for many years for minor surgical procedure in the extremities, and some reports show that this technique is useful to reduce the intensity of pain-related BTX-A application for PH [4].


We compare two anesthetic techniques to reduce pain-related BTX-A injections in PH, intravenous regional anesthesia or Bier's block (BB) and peripheral nerve blockade (PNB).

For BB, a venous catheter was inserted in a distal vein on the back of the hand. A proximal tourniquet was placed on the forearm. A distal Esmarch bandage was placed. We injected 30 ml of prilocaine 0.5 percent over 2 minutes through distal catheter. For PNB, the patients received regional block of median and ulnar nerves using the conventional technique (3 ml of lidocaine 2 % diluted in 3 ml of sterile saline solution).

Fifty patients with PH were treated with BTX-A injections, using a total dose of 50 U BTX-A for each hand. One palm pretreated with BB, while the other hand was pretreated with PNB. Sweat secretion was visualized with the Minor's test and pain related to BTX-A application was rated separately by each patient on a scale of 1 (no pain) to 10 (severe pain).


Comparison results between both anesthetic techniques are shown in Table 1. There were no differences on the intensity of pain-related BTX-A application in the arm anesthetized with BB than the one treated with PNB (mean 5 and 4 respectively, U-Mann Whitney, p= 0.983).

There were no local side effects on the hand pretreated with PNB. On the hand pretreated with BB, mild transitory paresthesia was observed. No side effects on the central nervous system were seen in both pretreatments.

Table 1. Comparison results between Bier's block and Peripheral nerve block (50 patients).
ResultsBier's blockPeripheral nerve block
Mean Intensity of pain (Scale 1-10)5 (range 3-7)4 (range 3-5)
Local side effectsMild, transitory paresthesiaNone
Systemic side effectsNoneNone
Special training requiredYesYes
CostLow (more equipment required)Low


In most studies of the treatment of PH with BTX-A, intracutaneous applications are performed under topical or regional anesthesia [5, 6, 7]. In regular practice, the most commonly used techniques are simple cooling and intravenous regional anesthesia. In the present study, BB and PNB proved to give similar results in the reduction of pain-associated to BTX-A treatment for PH.

The BB technique was first described by Bier in 1908. This technique has been demonstrated to be safe and effective when used appropriately. Nevertheless, sometimes it can induce side effects as toxic reactions (passage of the anesthetic into systemic circulation) and pain related to needle prick [3].

On the other hand, PNB provides sufficient anesthesia to make the injection of BTX-A painless. However, repetition of PNB can increase the risk of neural injury caused by mechanical or chemical damage [8].

Our results affirm that BB and PNB are effective techniques in reducing the pain suffered with BTX-A injections. Side effects of BB and PNB are mild and transitory if any. Administration of both techniques are reliable and easy. Blaheta et al [4], suggests that BB can be performed by trained dermatologists, and not only by anesthesiologists.

The BB technique have some side effects, all related to tourniquet release, as we observed in our study. The pain experienced by the patient was mild and generally due to needle pricks.


1. Swartling C, Naver H, Lindberg M. Botulinum A toxin improves life quality in severe primary focal hyperhidrosis. Eur J Neurol 2001; 8: 247-52.

2. Naumann M, Hofmann U, Bergmann I, et al. Focal hyperhidrosis. Effective treatment with intracutaneous botulinum toxin. Arch Dermatol 1998; 134: 1298-9.

3. Blaheta HJ, Vollert B, Zuder D, Rassner G. Intravenous regional anesthesia (Bier's block) for botulinum toxin therapy of palmar hyperhidrosis is safe and effective. Dermatol Surg 2002; 28: 666-71.

4. Blaheta HJ, Deusch H, Rassner G, Vollert B. Intravenous regional anesthesia (Bier's block) is superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis with botulinum toxin. J Am Acad Dermatol 2003; 48(2): 302-4.

5. Shelley WB, Talanin NY, Shelley ED. Botulinum toxin therapy for palmar hyperhidrosis. J Am Acad Dermatol 1998; 38: 227-9.

6. 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; 45: 587-9.

7. De Almeida AR, Kadune BV, de Oliveira EM. Improving botulinum toxin therapy for palmar hyperhidrosis: wrist block and technical considerations. Dermatol Surg 2001; 27: 34-6.

8. Campanati A, Lagalla G, Penna L, et al. Local neural block at the wrist for treatment of palmar hyperhidrosis with botulinum toxin: technical improvements. J Am Acad Dermatol 2004; 51: 345-8.

© 2006 Dermatology Online Journal