Intravenous regional anesthesia (Bier's block) is superior to a peripheral nerve block for painless treatment of plantar hyperhidrosis with botulinum toxin

Abstract

Severe focal hyperhidrosis may considerably reduce quality of life.1Swartling C Naver H Lindberg M Botulinum A toxin improves life quality in severe primary focal hyperhidrosis.Eur J Neurol. 2001; 8: 247-252Crossref PubMed Scopus (113) Google Scholar Topical therapies are not consistently effective in patients with severe plantar hyperhidrosis. Recently, botulinum toxin type A (BTX-A) has been demonstrated to be highly effective in reducing focal hyperhidrosis.2Naumann M Hofmann U Bergmann I Hamm H Toyka KV Reiners K Focal hyperhidrosis. Effective treatment with intracutaneous botulinum toxin.Arch Dermatol. 1998; 134: 1298-1299Crossref PubMed Scopus (209) Google Scholar BTX-A inhibits sweat production by blocking the release of acetylcholine from presynaptic membranes in a local and reversible fashion.3Shone CC Clostridium botulinum neurotoxins, their structures and modes of action.in: Natural toxicants in foods. Ellis Harwood Ltd, Chichester1986: 11-57Google Scholar However, pain from the intradermal injections is difficult to tolerate, and topical anesthesia methods provide unsatisfactory relief. Invasive local anesthetics used in performing the technique of the administration of intravenous regional anesthetic (IVRA) has been used elsewhere, especially for minor surgical interventions of the extremities.4Brown EM McGriff JT Malinowski RW Intravenous regional anaesthesia (Bier block): review of 20 years' experience.Can J Anaesth. 1989; 36: 307-310Crossref PubMed Scopus (122) Google Scholar Recently, we have demonstrated that IVRA is an effective and safe procedure for BTX-A treatment of patients with palmar hyperhidrosis.5Vollert B Blaheta H-J Moehrle E Juenger M Rassner G Intravenous regional anaesthesia for treatment of palmar hyperhidrosis with botulinum toxin type A.Br J Dermatol. 2001; 144: 632-633Crossref PubMed Scopus (19) Google Scholar Alternatively, peripheral nerve blockade may be used for sufficient anesthesia.6De-Almeida AR Kadunc BV De Liveira EM Improving botulinum toxin therapy for palmar hyperhidrosis: wrist block and technical considerations.Dermatol Surg. 2001; 27: 34-36Crossref PubMed Google Scholar In the present study, IVRA was applied for treatment of plantar hyperhidrosis to investigate its effect on pain relief in comparison to a regional nerve block. The overall subject's acceptance of the two anesthesia methods was rated by means of a questionnaire. In a pilot study, 8 patients with excessive plantar hyperhidrosis resistant to any previous therapy were treated with intracutaneous injections of BTX-A (BOTOX, Allergan, Irvine, Calif). A total dose of 100 MU/5 mL NaCl BTX-A was used for each sole. In 5 patients, the technique of IVRA was used for regional analgesia. A venous catheter was inserted in a distal vein on the back of the foot. Then, a tourniquet cuff was placed on the lower leg using an electronic double-cuff system (VBM Medizintechnik, Sulz, Germany). After exsanguination, the tourniquet was inflated to a pressure of 250 to 300 mm Hg, and 40 mL of prilocaine 0.5% (Xylonest, AstraZeneca, Wedel, Germany) were injected into the distal vein catheter. Twenty minutes after injection of the prilocaine, BTX-A injections were performed. After an additional 10 minutes the double cuff was slowly (over 3 to 4 minutes) released. Because of possible side effects of the local anaesthetic, blood pressure and ECG status were monitored continuously during the IVRA procedure. In 3 patients, peripheral nerve blocks (a selective ankle block in 2 patients and a popliteal nerve block in 1 patient) were performed in accordance to current standard guidelines.7Scott DB Techniques of regional anaesthesia. Thieme, New York1998Google Scholar Subsequently, pain was rated by the patient scoring: painless (score 0), weak (score 1), moderate (score 2), very painful (score 3). A visual analog scale was used for measurement of acute pain.8Bijur PE Silver W Gallagher EJ Reliability of the visual analog scale for measurement of acute pain.Acad Emerg Med. 2001; 8: 1153-1157Crossref PubMed Scopus (1097) Google Scholar In addition, the overall acceptance of both anesthesia methods was rated by patient scoring: well tolerated (score 0), moderately pleasant (score 1), unpleasant (score 2), not at all tolerated (score 3). Before and 2 weeks after BTX-A injections, the hyperhidrotic area was assessed by Minor's test and the hyperhidrosis was quantified by measuring the spontaneous sweat secretion using the Corneometer (Courage & Khazaka Electronic GmbH, Cologne, Germany). Subjective ratings by the patients have demonstrated that BTX-A injections were less painful (mean, 0.05) in patients anesthetized with IVRA than in those treated by a peripheral nerve blockade (mean, 0.5) (Fig 1). With regard to the overall acceptance of both anaesthesia techniques, IVRA was much better tolerated by the patients (mean, 0.2) than the peripheral nerve block (mean, 1.6) (Fig 1). BTX-A reduced plantar hyperhidrosis; the spontaneous sweat production measured by the Corneometer declined significantly from 101.6 before to 77.9 2 weeks after the BTX-A injections (Fig 2). Fig. 2Reduction of sweat secretion as measured by Corneometer.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In our report, IVRA was more effective than a peripheral nerve block in reducing the pain experienced upon injections. The technique of IVRA was also a safe anesthesia procedure when used according to standard guidelines; no side effects were observed. The major advantages of Bier's block are reliability and ease of administration. In the present study, IVRA was easily performed by dermatologists confirming previous results of our group.9Blaheta H-J Vollert B Zuder D Rassner G Intravenous regional anaesthesia (Bier's block) for botulinum toxin therapy of palmar hyperhidrosis is safe and effective.Dermatol Surg. 2002; 28: 666-672Crossref PubMed Scopus (47) Google Scholar Therefore, we suggest that the use of Bier's block is not limited to anesthetists but may also be performed by dermatologists after significant training has been completed and with adherence to a strict protocol. In addition, the procedure of IVRA was much better tolerated by the patients than was peripheral nerve block. This result was mostly because of the rapid recovery of motor function and sensation after tourniquet release. In using a peripheral nerve block, the outpatient visit was prolonged because of the longer duration of this anesthesia method. This issue is of major relevance for an outpatient procedure such as BTX-A therapy. Moreover, our data demonstrated that BTX-A significantly reduces focal hyperhidrosis, confirming previous reports.2Naumann M Hofmann U Bergmann I Hamm H Toyka KV Reiners K Focal hyperhidrosis. Effective treatment with intracutaneous botulinum toxin.Arch Dermatol. 1998; 134: 1298-1299Crossref PubMed Scopus (209) Google Scholar, 5Vollert B Blaheta H-J Moehrle E Juenger M Rassner G Intravenous regional anaesthesia for treatment of palmar hyperhidrosis with botulinum toxin type A.Br J Dermatol. 2001; 144: 632-633Crossref PubMed Scopus (19) Google Scholar *Funding sources: Supported in part by Allergan, Irvine, Calif. Conflict of interest: None identified. For reprints of this letter contact Barbara Vollert, MD, Department of Dermatology, Eberhard-Karls-University, Liebermeister Str 25, 72076 Tuebingen, Germany. E-mail: [email protected] .