Botulinum toxin A blocks neuronal acetylcholine release at the neuromuscular junction and in cholinergic autonomic neurons; it thus disconnects axillary sweat glands from their innervation. In an elegant study, Heckmann et al demonstrated quantitatively the effective safe treatment of axillary hyperhidrosis by intradermal injection of botulinum toxin A. They also demonstrated the longevity of the relief produced: 24 weeks after the injection of 100 U, the rates of sweat production (in the 136 patients in whom the rates were measured at that time) were still lower than baseline values (67 ± 66 mg/min in the axilla that received 200 U and 65 ± 64 mg/min in the axilla that received placebo and 100 U of the toxin).
A study by Brehmer et al indicated that the duration of botulinum toxin A’s effects in primary axillary hyperhidrosis increase with successive treatments. The first injection, in 101 patients, had a median efficacy of 4.0 months, compared with 4.5 months for the second treatment and 5.0 months for the third injection. [11]
BOTOX® injections have become an established and, often, effective treatment for axillary hyperhidrosis. This treatment has also raised the profile of the condition with insurers. Although effective, the success of the treatment seems to be quite technique-dependent (ie, the treatment works when injections are done by one practitioner and not when done by another). Major drawbacks are the expense of the toxin and the need for repeated treatments.
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Surgical treatment of axillary hyperhidrosis. Staggered-cross incision of a classic Skoog procedure. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Karpinski modification of the classic Skoog procedure incision. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Iodine/starch test: Iodine tincture or Betadine applied and air dried. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Iodine/starch test: Cornstarch powdered onto dried iodine. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Iodine/starch test: As sweating begins, iodine and starch react wherever dampened to produce a blue color. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Iodine/starch test: Further color development (see Image 6). Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Iodine/starch test: An indelible marker outlines the area positive for hyperhidrosis. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Preoperative axilla in a healthy young writer with axillary hyperhidrosis. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Outline of the operative site as estimated by the hair pattern (not by mapping). Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Anesthesia is attained by infiltration of local anesthetic. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The transverse incision is made, here exposing the subcutaneous sweat glands. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Through the rather limited incision, dissection is carried to the entire outlined area. The dissection is deep to the glands but superficial to axillary fascia. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: In the recess of the incision, the shiny and somewhat striated axillary fascia is visible. In conducting the operation, no part of the dissection should violate this fascia. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Once the flaps are elevated and hemostasis is achieved, the flaps are everted and the layer of the glands snipped off the undersurface of the dermis. Here, the upper portion of the flap has been cleared of sweat glands, while the gland lobules are still visible on the lower portion of the flap. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. The carpet of glandular tissue is seen intact on the left side of the skin flap, while the glands have been resected on the right side of the flap, revealing the underside of the dermis. The axillary fascia is visible as a glistening sheet above the skin flap. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Once the skin flaps are cleared of sweat glands, the dermis should be visible along with the bulbs of many hair follicles. Although not seen clearly in this photo, the fine vessels of the subdermal plexus should be visible under magnification as a network of red vessels. The posture of everting the flap over the surgeon's finger to facilitate gland dissection is demonstrated. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: At the completion of gland resection, vascularity of the flaps should show no compromise. Hemostasis should be meticulous. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: A drain has been led out through a small incision at the most proximal area dissected. This spot will be the most dependent when the patient is up and about. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The incision has been closed in two layers, and the drain secured with a single suture. The needle end of the drain can be inserted into a Vacutainer red top tube to supply gentle suction once the incision is closed. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Incision is closed and drain is in place. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The bandage should be padded and should overlie the entire dissected area. The distal portion can be held in place by wrapping the arm, and the proximal portion needs to be attached to the chest so that the dressing acts like a hinge when the arm is abducted. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: The completed dressing, in this case using a self-adherent stretchy flexible bandage on top of surgical paper tape and Tegaderm. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Modified Skoog procedure: Resulting scar at 2 months after surgery. Note the normal texture and appearance of axillary skin and the normal hair pattern. The pink coloration usually is gone at 4-5 months. Image courtesy of Richard H S Karpinski, MD.
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Surgical treatment of axillary hyperhidrosis. Professor Tord Skoog (1915-1977).
