Alternative to Botox for underarm sweating

Palm Desert, Calif. - As an alternative to the increasingly popular option of using botulinum toxin type A (Botox, Allergan) to treat excessive underarm sweating, some patients are experimenting with undergoing surgery that they report to be more lasting.

"Axillary skin excision is a technique that was first described in the 1960s," says Clifford M. Lawrence, M.D., a consultant dermatologist at the Royal Victoria Infirmary at the University of Newcastle upon Tyne in the United Kingdom.

"I wanted to remind people of the advantages of this technique. Effectively, it has been forgotten by the dermatologic community."

"It takes the surgeon about 30 minutes to do the procedure," Dr. Lawrence says. "We recommend that patients not go back to a very physical job if that is their occupation, immediately after the surgery. We would recommend that they take some time off work. It's recommended to avoid excessive sweating in general following the procedure so the underarm remains dry, and the risk of infection is minimized. We would rule against strenuous physical exertion."

He notes that several studies conducted in the 1980's used axillary skin excision, involving resection of a longitudinal ellipse of axillary skin and Z-plasty closure. One pitfall has been extensive scarring at the surgical site.

"The ellipse of skin that is resected should be 10 mm wide and 40 mm long," Dr. Lawrence tells Dermatology Times.

"The other essential point is to selectively snip off sweat glands from the under surface of the surrounding sweat producing axillary skin. Physicians who have employed the technique have taken out bigger and bigger pieces of skin, which makes it less attractive as an option, because of extensive scarring and other complications.

"My sense is that they didn't understand how to do the technique as it was originally described," he says. "I get the impression that axillary skin excision is currently employed very rarely."

Botox shortcomings

Patients who have not responded to Botox treatment have looked for other possible solutions to axillary hyperhidrosis, Dr. Lawrence explains. One of the shortcomings of Botox is its lack of permanence: injections may be required anywhere from every six or eight months, depending upon the type of hyperhidrosis that is being treated.

"It's true that Botox does not produce scarring and is not painful, but on the other hand it requires repeat injections," Dr. Lawrence says, noting he may administer analgesics to patients to relieve post-surgical pain following axillary skin excision.

"The other issue is cost," Dr. Lawrence says. "There is a one-time cost associated with surgery where there is an ongoing expense to having Botox injections. If we can reduce the problem surgically, so it's tolerable, that might be a better option."

Dr. Lawrence routinely measures the rate at which patients sweat to determine if they are suitable candidates for the surgical procedure.

"People may have a perception that they have sweaty armpits, but it should be objectively measured if it merits treatment," he says. "If in fact, their rate of sweat falls within the normal range, I won't recommend surgery. If it is in the normal range, they might be better served by Botox injections because they won't get scarring."

Unlike the endoscopic transthoracic sympathectomy, which has been used as a treatment for axillary hyperhidrosis, axillary skin excision does not produce compensatory sweating at other sites on the body.

Indeed, nearly one out of every two patients who have endoscopic transthoracic sympathectomy experience compensatory sweating at other body sites that are less exposed, such as the trunk or on the thighs, particularly during physical exertion or during very warm weather.

A randomized, controlled trial comparing the efficacy of Botox injection to axillary skin excision to treat hyperhidrosis would highlight the advantages and disadvantages of each modality, according to Dr. Lawrence.