What creates a wrinkle?
Many wrinkles are actually creases that have been worn into the skin by making the same expression thousands of times. These "expression lines", often-called frown lines or crow's feet are due to the contraction of a muscle under the skin in that area. We have known for years that surgically cutting that muscle will improve the wrinkle.

What is Botox® ?
Botox® is a purified protein toxin produced by the clostridium botulinum bacteria. Although Botox® is a toxin, there have been no serious side effects. This is because, for the treatment described, it is used in extremely small amounts and does not spread throughout the body.

TORONTO, Apr 23 (Reuters Health) - Migraine patients treated with pericranial intramuscular injection of botulinum toxin type A (Botox) had a significant reduction in the frequency and severity of migraine during the subsequent 3-month period, a multicenter group reported at the annual meeting of the American Academy of Neurology here.

Dr. Ninan T. Mathew reported the findings of the Botox Migraine Study Group from a safety and efficacy trial of pericranial botulinum toxin injection in 123 patients with IHS-defined chronic migraine. The subjects, who averaged about 4 migraine attacks per month, were randomized to receive 0, 25, or 75 U Botox injected into glabellar, frontalis, and temporalis muscles.

How is Botox® given?
A very small needle is used to inject small drops of Botox® into the skin approximately 1 cm apart for treating excessive sweating and into the muscles to prevent wrinkles (frown lines & crows feet etc.). The procedure takes only a few minutes in the office and requires no anesthesia. Heavy physical exercise should be avoided for several hours, but patients may engage in any normal activity.

When will Botox® take effect?
Your will notice 95% improvement within 48 hours and the full effect will be seen in about 1 week.

How long does Botox® last?
Most patients will obtain 6 to 10 months of results with one treatment of Botox®.

What are the risks and complications?
The only complications from injection into the skin are:
1) Tiny bruises are occasionally seen which fade in a few days
2) Occasionally small persistent areas of sweating that may need a second treatment session
3) Some temporary weakness in grip strength when injected into the palm, which may last up to two weeks. There is no risk of numbness, or permanent weakness.

Who are good candidates for "No Sweat" Botox®?
People with unwanted palmar sweating...
1) People working in retail who handle sensitive material such as salespeople in clothing, jewelry, stationery, accessories;
2) People working in hot conditions such as models, television newscasters, chefs and photographers;
3) People handling lots of paper such as executives, attorneys, salesmen, stockbrokers and title company workers
4) People who need to use keyboards extensively such as typists, computer programmers and software engineers; and people who handle money such as cashier tellers and reception desk personnel.

Can I treat hands, feet, and underarms all at the same time?
You can certainly treat both underarms at the same time. There is no danger of muscle weakness in the underarms because the doses used are relatively small compared to the massive bulk of the muscles underlying the axillary skin.

However, we generally do not like to treat both palms simultaneously because at least 25% of the patients get some mild transient weakness of some of the muscles of the fingers or hand which lasts about 10 days to 2 weeks on average. Therefore we generally treat one hand and wait a week or two to treat the second hand.

Also, we do not like to use more than 200 units in one treatment session regardless of where the Botox® is placed. This is because there is some suggestion in the medical literature that sensitization may occur when repeated doses of more than 200 units at one time are used. If one becomes sensitized to the Botox®, the body manufactures an antibody against the toxin and it will no longer have any effect whatsoever! This is the last thing we would want to have happen since it would mean the drug would be forever useless for the sensitized individual.

How much does it cost?
It depends on the surface area being treated. A smaller person with small hands, small axillary (underarm) skin, or small feet will require less medication to treat than a person with larger hands, feet, underarms, etc. This is because the Botox® is injected in very small amounts, typically 0.1 ml per site with 1-2 units per site. The Botox® will diffuse a short distance in the axillary skin, usually 1.0 cm (half inch) in all directions. By overlapping the circles of diffusion, it will cover the entire axilla if you inject small amounts spaced about 1.5 cm apart. A typical underarm will require 100 - 120 units total (50 - 60 per armpit). At current prices for the material, we charge $8 per unit. To treat two underarms then costs $800-$1,000.

Palms and soles require more material because the skin is thicker and the drug does not spread as easily through the thicker skin. Therefore you need to space your injections closer together, typically 0.75 cm apart. You therefore need more injections to cover the palm and fingers. An average hand uses 100 units or more per palm.

What are the alternative treatments?
Topical Anti-perspirants
Topical antiperspirant sticks, creams, lotions, and solutions typically use aluminum chloride solutions. They are highly irritating with continued use, and largely ineffective for people with excessive sweating.

Medications (Anti-cholingeric drugs & tranquilizers)
Medications currently used cause dry mouth, blurred vision and minimally reduce sweating. Tranquilizers may minimize your anxiety over sweating but rarely diminish the flood.

Tap Water Iontophoresis
Various battery powered electrical devices have been used over the years, which use a tap water moistened pad and electrical current held against the palms for several hours. This decreases the sweating but is very time consuming, needs to be repeated on a daily or weekly basis, and is only mildly effective for severe cases.

Surgery
Thoracic surgeons and neurosurgeons use a fiberoptic surgical tube inserted into the neck or through the underarm skin to cut the nerve fibers next to the spine which lead to underarm sweat glands and palms (endoscopic sympathectomy or ETS). This approach involves the risks of localized paralysis, loss of sensation and even drooping eyelid or permanent dilation of the pupil of the eye as a reflex injury. Cases of compensatory hyperhidrosis where there is an unwanted increase in sweating elsewhere have been reported.

How does the Botox® paralyze the sweat glands?
The sweat glands require stimulation by the nerve fibers, which are part of the sympathetic nervous system. These fibers originate in the spinal cord and extend up to the undersurface of the skin where they branch into tiny fibers that extend to the sweat glands. Botox® inhibits the release of the chemical messenger, which is released at the nerve endings and is required to stimulate the sweat glands. If there is no release of the chemical messenger, there is no stimulation of the glands. If there is no stimulation, the glands simply sit there doing nothing and the skin remains dry.

What causes excessive sweating?
Hyperhidrosis is the medical term for excessive sweating. Sweating is caused by stimulation of the sweat glands by the nerve endings from higher centers in the brain. These nerves respond to different kinds of stimuli:
· Emotional stress like intimate social situations or public speaking.
· Physical stress like the increased body temperature that comes with exercise or hot and humid weather.

Some people are plagued with excessive sweating on a round-the-clock basis. Other people are only bothered when they are under emotional stress, physically active, or over-heated. In either case, Botox® Purified Neurotoxin Complex may be the answer.

The nerves that control sweating depend upon a chemical transmitter called Acetylcholine, which is a molecule produced at the very ends of the nerve fibers. Botox® is a genetically engineered neurotoxin, which can, when injected into the skin, block the release of the Acetylcholine to the sweat glands for months!

Why do I have hyperhidrosis?
People with hyperhidrosis have higher than normal- levels of nerve stimulation of the sweat glands. This stimulation can be more or less continuous in some patients, obviously those who sweat all the time. Or it can be intermittently active, triggered by heat, anxiety, or physical stimulation like application of creams to the skin or simply washing the skin. Patients with hyperhidrosis often report other symptoms suggestive of high rates of sympathetic nerve activity: higher resting pulse rate, flushing of the skin, sensations of warmth, etc. No one knows why this increased nerve tone is present. There is clearly a genetic influence, however, as we frequently see groups of sweaters in the same family.

Can you get compensatory hyperhidrosis from tile use of Botox®?
No, The effects of the Botox® are strictly focal. Since only small surface areas are treated (axillary skin, palms, soles, upper forehead etc.) the rest of the skin on the arms, legs, torso, and face sweats as before. There is no compensatory hyperhidrosis reported and we have not observed any in the many cases we have treated.

How do you know exactly where to inject?
We can apply a tincture of iodine to the skin and then dust it lightly with cornstarch powder (so-called Minor Starch Test). The perspiration combines the iodine and glucose in the starch and turns instantly black which makes identifying the hyperhidrotic areas very easy. It is mandatory to map out the sweating pattern this way as the physician can easily miss some of the active areas. We repeat the test after the treatments to evaluate the presence of any persistent areas and document the extent to which the sweating has diminished.

How many treatments does it take to treat underarms, palms, and feet?
The typical axillary sufferer will be treated on both sides on the initial visit. We like to see the patients again in about two weeks to touch up any spots still sweating which might have been missed in the initial treatment session. Palmer patients are more difficult to treat. We will generally see significant decrease in sweating with the first injections, but generally for the very heavy sweaters, we will need to touch up persistent spots at a second visit 7 to 10 days later. We can begin treating the second hand at that point as well, and follow-up with a third visit in another 7 to 10 days. Feet are somewhat easier since the toes are smaller in surface area than the fingers and do not require as many injections.

Does Botox® work for facial sweating?
We have successfully treated a number of patients who have sweating of the anterior scalp and upper forehead. They behave much the same way as the patients with axillary sweating. The Botox® appears to diffuse fairly well in the upper forehead skin. The periods of dryness are about the same. Part of the difficulty knows how far back into the scalp to carry the injections. Most of the patients treated so far are happy with the upper half of the forehead and anterior 1/3 of the scalp treated, but it probably varies a good deal from patient to the patient.

Does insurance cover the cost of the treatment?
Not yet, and given the high cost of the material, it seems unlikely that the insurers are going to willingly cover the treatment. Sadly, most people by now are more than familiar with the reality that the insurers make money by collecting premiums and denying claims for payment. Using Botox® to treat hyperhidrosis is a so-called "off-label" use, meaning that, although the drug is FDA approved, at present the only approved indications are for blepharospasm (twitches around the eye muscles) and dystonia (involuntary muscle spasm). The company has not yet applied for nor received FDA approval for the indication of hyperhidrosis. Any physician, duly licensed, may use the Botox® for any use, which he or she deems in the best interest of the patient. The FDA recognizes off-label uses as a normal part of traditional and mainstream medicine. This is often the way that new uses for existing medications are discovered.

Because of the enormous cost of conducting the clinical trials and completing the paper work necessary to receive a new approved indication from the FDA, it seems highly unlikely that the manufacturer will pursue a new approval application at this time. But we are free to use the drug in our professional capacity as physicians in the best interest of our patients. The bottom line is that the insurers use the "off-label" excuse not to reimburse for treatment of hyperhidrosis. It is not rational, but then neither is the medical system.

Typically, only one palm is treated with injections on the first visit. Prior to treatment with Botox®, the palm is wiped with iodine and starch powder. The deep purple-black color shows the extent of the sweating before treatment with Botox®. The starch test is then repeated to identify any areas, which were missed and inject those areas. On the second visit the treatment is repeated on the alternate hand. One week after treatment of both palms, the starch test is repeated on the first hand to demonstrate the extent of dryness that has been achieved.