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Use of Needle-Free Anesthesia in the Treatment of Palmar HH

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Use of needle-free anesthesia in the treatment of palmar hyperhidrosis with botulinum A toxin.

by Antranik Benohanian, MD, FRCPC. Montreal, Quebec, Canada.

From the Division of Dermatology, Department of Medicine, University of Montreal.

Journal of American Academy of Dermatology, 2005, 52:1073.

Botulinum toxin type A (BTX-A) is a useful treatment for palmar hyperhidrosis [1], especially when conservative measures fail. However, palmar injection of BTX-A with a needle is painful. The standard method of analgesia, nerve block of the wrist, has potential drawbacks: vascular puncture, impaired hand dexterity, and nerve scarring from repeated injuries [2]. Alternative analgesia consists of a standard skin wheal of local anesthetic raised on the palms with a needle, but it may also be painful. Because jet injection of local anesthetic reduces pain [3], needle-free lidocaine injections prior to BTX-A injections (with a needle) are a reasonable option. (Reconstitution of BTX-A with lidocaine does not jeopardize toxin potency [4].)

TECHNIQUE

The technique is easy to perform, quick, and welltolerated. Map out the BTX-A injection sites on the palm. Prepare the needle-free injector (MED-JET; Medical International Technologies Canada, Montreal, Quebec, Canada; Fig 1) by adjusting the volume per spurt to 0.02 mL (range, 0.01-0.1 mL) and adjusting the pressure system so that the injection reaches the desired depth. Use the MED-JET to produce superficial skin wheals of lidocaine 2% over the entire palmar surface, 1.5 cm to 2 cmapart (Fig 2). Then inject BTX-A with a 31-gauge needle. The metal component of the MED-JET requires sterilization at 1348C with an autoclave for 30 minutes; the plastic component undergoes only cold sterilization.

Side effects include small bruises (of about 1 mm) that fade after a few weeks (Fig 3).

The cost of a MED-JET unit is $5000 (US).

In conclusion, this technique has the potential to replace peripheral nerve blockade prior to BTX-A injections for the treatment of palmar hyperhidrosis. It may also be used for plantar hyperhidrosis.

Fig 1. Needle-free injector. The MED-JET MBX model is produced by Medical International Technologies Inc (Montreal, Quebec, Canada), a subsidiary of Medical International Technology USA.

Fig 2. Lidocaine injection sites 1.5 cm to 2 cm apart.

Fig 3. Minor bruising shown 24 hours after injections.

REFERENCES:

1. Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H, et al. Multi-Specialty orking Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol 2004; 51:274-86.
2. Hayton MJ, Stanley JK, Lowe NJ. A review of peripheral nerve blockade as local anaesthesia in the treatment of palmar hyperhidrosis. Br J Dermatol 2003; 149:447-51.
3. Koenig HM, Paisansathan C, Albrecht RF 2nd, Zsigmond EK. Jet injection of local anesthetic decreases pain of arterial cannulation in awake neurosurgical patients. J Neurosurg Anesthesiol 2004;16:156-9.
4. Gassner HG, Sherris DA. Addition of an anesthetic agent to enhance the predictability of the effects of botulinum toxin type A injections: A randomized controlled study. Mayo Clin Proc 2000;75:701-4.

Funding sources: Allergan Inc. provided editorial assistance.

Conflicts of interest: None identified.

Reprint requests and correspondence: Antranik Benohanian, MD, Centre Hospitalier de l’Université de Montréal, 1058 Rue Saint-Denis, Montréal, QC, H2X 3J4, Canada. E-mail: info@benohanian.com.

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