Correspondence

Botulinum Toxin, Sweating, and Body Odor

N Engl J Med 2002; 347:620-621August 22, 2002

Article

To the Editor:

Since our description of the anhidrotic effect of injections of botulinum toxin A in humans,1 there have been several studies confirming the efficacy and safety of botulinum toxin injections in several forms of focal hyperhidrosis, including the study reported in the Journal by Heckmann et al. (Feb. 15, 2001, issue).2 The injections have been shown to be particularly useful in axillary hyperhidrosis and are now used widely.2,3 The excellent response of axillary hyperhidrosis to botulinum toxin injections is due to the fact that the hyperactive sweat glands are usually localized in one or two small areas within the hair-bearing axillary skin. Since the toxin diffuses, causing a dose-dependent anhidrotic circle, two to three injections are usually sufficient to denervate the oval hair-bearing area of the axilla without decreasing the efficacy of the toxin.4 However, in most published studies, as many as 14 injections were used, which makes the procedure unnecessarily painful. We recommend the use of only two to four injections in each axilla in order to minimize discomfort and risk.

Magda Amin Bushara, M.D.
Botulin Clinic, Eden Prairie, MN 55344

Khalaf Bushara, M.D.
Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417
busha001@umn.edu

4 References

1
Bushara KO, Park DM. Botulinum toxin and sweating. J Neurol Neurosurg Psychiatry 1994;57:1437-1438
CrossRef | Web of Science | Medline

2
Heckmann M, Ceballos-Baumann AO, Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med 2001;344:488-493
Full Text | Web of Science | Medline

3
Glogau RG. Botulinum A neurotoxin for axillary hyperhidrosis: no sweat Botox. Dermatol Surg 1998;24:817-819
CrossRef | Web of Science | Medline

4
Bushara KO, Park DM, Jones JC, Schutta HS. Botulinum toxin -- a possible new treatment for axillary hyperhidrosis. Clin Exp Dermatol 1996;21:276-278
CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Bushara et al. deserve credit for showing that as few as two injections of botulinum toxin A per axilla suffice to produce anhidrosis in healthy volunteers.1 The rate of axillary sweat production is typically below 25 mg per minute in normohidrotic persons but can reach 1000 mg per minute in patients with hyperhidrosis. In view of this difference, it seems appropriate to adhere to injection protocols that have proven efficacy for treating severe axillary hyperhidrosis. When 30-gauge needles were used for 10 injections, 98.6 percent of our patients rated their tolerance of treatment as excellent or good.

There is a second difference between normohidrotic persons and those with hyperhidrosis: the former often report having unpleasant axillary odor, whereas the latter typically do not.2 Body odor is attributed to the production by apocrine axillary sweat glands of a turbid secretion that has a pungent smell when it is degraded by microbes that are resident in the skin.3 It has been suggested that apocrine activity in persons with hyperhidrosis does not parallel the activity of eccrine and apoeccrine glands.2 Some patients with hyperhidrosis become more aware of their body odor after botulinum toxin injections. In contrast, a substantial reduction in body odor was found in normohidrotic healthy volunteers in whom one axilla was injected with botulinum toxin A and then compared with the other axilla.4 This finding further supports the concept that normohidrotic persons and those with hyperhidrosis differ in the quantity and quality of sweat secretion. Both the extent of moisture and the extent of odor of the axillary milieu differ. Therefore, the effects of botulinum toxin injections on the two variables are not the same in healthy volunteers and patients with hyperhidrosis.

Marc Heckmann, M.D.
Gerd Plewig, M.D.
Ludwig Maximilians University, D-80337 Munich, Germany
heckmann@derma.med.uni-muenchen.de

Bettina M. Pause, Ph.D.
Christian Albrecht University, 24098 Kiel, Germany

4 References

1
Bushara KO, Park DM, Jones JC, Schutta HS. Botulinum toxin -- a possible new treatment for axillary hyperhidrosis. Clin Exp Dermatol 1996;21:276-278
CrossRef | Web of Science | Medline

2
Sato K, Kang WH, Saga K, Sato KT. Biology of sweat glands and their disorders. II. Disorders of sweat gland function. J Am Acad Dermatol 1989;20:713-726
CrossRef | Web of Science | Medline

3
Leyden JJ, McGinley KJ, Holzle E, Labows JN, Kligman AM. The microbiology of the human axilla and its relationship to axillary odor. J Invest Dermatol 1981;77:413-416
CrossRef | Web of Science | Medline

4
Heckmann M, Teichmann B, Pause BM, Plewig G. Botulinum toxin-A reduces axillary body odor. Naunyn Schmiedebergs Arch Pharmacol 2002;365:Suppl 2:R23-R23 abstract.
Web of Science

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