SweatSolutions.org: Expert Answers to Frequently Asked Questions About Botox

July/August 2006 Edition Table of Contents:

» Finally, Help for Our Most Troubling Question

» Calling All Physicians: Join Us 2-for-1 Now!

» Tips to Beat Sweaty Feet, and Save Money

» Expert Answers to Frequently Asked Questions About Botox

» New CPT Codes for Treatment of Hyperhidrosis

» View Events

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Expert Answers to Frequently Asked Questions About Botox

(July/August 2006) This past May, the results of an interesting case report of ten patients suffering from depression were released in the journal of the American Society for Dermatologic Surgery (the journal is called Dermatologic Surgery). According to the report, patients who were given injections between their eye brows to smooth frown lines experienced dramatic decreases in symptoms of depression. More research into this phenomenon is required before we can say whether Botox injections can truly cause depression to lift. In the meantime, the jury is still out on this potential use for Botox.

The proverbial jury has, however, come to a clear conclusion regarding Botox for hyperhidrosis. We know from the letters, e-mails, and phone calls we get from hyperhidrosis patients that Botox injections for excessive sweating can significantly improve quality of life. But we've got more than anecdotes to back this up.

For instance:

Data from the first long-term study of repeated treatment with Botox (botulinum toxin type A) for severe underarm sweating shows that Botox treatment is safe and effective and consistently results in meaningful, long-lasting improvements in symptoms, daily functioning, and quality of life.

And a study presented at a recent meeting of the American Academy of Dermatology indicates that treatment with Botox for axillary hyperhidrosis (excessive sweating of the underarms) greatly improves on-the-job productivity.

But while these and numerous other studies validate the use of Botox treatments for hyperhidrosis, we've found that our readers still have A LOT of questions about this treatment. To help us answer them, we recruited President and Founding Member of the International Hyperhidrosis Society, Dr. David Pariser. Dr. Pariser is a professor in the Department of Dermatology at Eastern Virginia Medical School in Norfolk, Virginia, and Secretary/Treasurer for the American Academy of Dermatology.

SweatSolutions:
Dr. Pariser, you have successfully treated hundreds of patients with Botox for hyperhidrosis so we're sure you hear this question all the time � does it hurt?

Dr. Pariser:
Well, each and every one of us has a different perspective on pain and a different pain threshold. So what is only mildly uncomfortable to one person might be very painful to another. Pain is always difficult to measure. That said, out of the hundreds of patients I've treated with Botox injections for underarm (axillary) hyperhidrosis, I've never had a single patient say "Stop, I don't want to do this." For most patients, even without any form of pain relief, the discomfort of underarm Botox injections is minimal to mild. Patients have said the pain is less severe than the pain of having blood drawn for a routine blood test. I've only had one or two patients tell me that it's very painful; to help those patients, I used a pain-relieving cream.

Botox injections for palmar hyperhidrosis are another story. Injections in the hands are very painful and very few people can tolerate them without anesthesia. This should not, however, dissuade those suffering from excessively sweating hands from seeking Botox treatment. We have very effective ways of providing pain relief during the treatment process. One way to relieve pain is to use a nerve block for palmar injections, but the simple use of ice and pressure works very well, too. I�m almost ready to give up nerve blocks altogether.

SweatSolutions:
How long does a Botox treatment for the underarms take and how frequently does a patient have to return to the office to be re-treated?

Dr. Pariser:
In my practice we pretty much have the process down to a science. We are very efficient � when a patient arrives for treatment I usually have everything set up and I have my assistant ready. Under these circumstances, I can inject two underarms in five minutes. Of course, when I was first injecting it would take a lot longer. As with anything, with practice comes efficiency. I would not expect that all physicians could provide the treatment so quickly, but the process doesn't need to be time-intensive. I�ve trained my physician assistants to inject and they can help me, or do the injections by themselves with my oversight.

Most of my patients who have insurance coverage for their hyperhidrosis treatments return to me every six months to be re-treated. People who are paying for the treatment out-of-pocket may, however, choose to stretch out the time between treatments and save some money. These folks tend to return every nine or ten months and are quite satisfied with that.

SweatSolutions:
You mentioned cost. How much does Botox treatment for hyperhidrosis typically cost?

Dr. Pariser:
Out-of-pocket costs for a patient obviously vary greatly depending upon whether or not health insurance is picking up some or all of the costs and whether the treatment is for excessive sweating of the underarms, hands, or both. Just to purchase the Botox itself in a large enough quantity to treat the hands, for instance, costs $1,000 to $2,000. For underarms, the Botox alone costs about $500 to $1000 dollars.

The cost for the administration of the treatment varies greatly. If insurance is helping to pay for the service then a patient will need to pay only the usual office copay. Keep in mind that some insurance policies carry a much higher copay structure than others.

First and foremost, I'd recommend asking your physician (preferably a dermatologist) to check if your insurance covers any or all of the treatment and then to also talk to another physician or two to get an idea of how much you might have to pay out-of-pocket. It is okay to comparison shop, but of course you want to find both quality care and affordable care.

SweatSolutions:
Which leads to our next question, how does a hyperhidrosis sufferer find the right physician?

Dr. Pariser:
You want to find someone who is experienced in treating hyperhidrosis not just with Botox, but with topical products and iontophoresis for the hands and feet, as well. Maybe Botox isn't the best choice for you � you want a physician who knows about all the available options. A good place to start is with the Physician Finder on the International Hyperhidrosis Society's Web site. Physicians who have listed their practices on the Physician Finder have indicated that they are interested in treating hyperhidrosis and those physicians who have attended one of our intensive hyperhidrosis continuing medical education programs receive a special designation in the Physician Finder. If you see a physician with that designation ("I'm Up To Date"), at least you know that they've been taught the treatment methods that our group believes to be the best.

If you can't find a physician in your general area who is listed in the Physician Finder, or even if you can, be sure to ask any physician you are considering (and we believe dermatologists are often your best choice) how experienced he or she is with treating hyperhidrosis. A doctor should not be insulted if you ask how many times he or she has provided Botox injections for hyperhidrosis and what his or her success rate has been.

Botox injections for underarm excessive sweating are fairly easy to administer. It's not a difficult procedure and most doctors can learn how to do it rather quickly. With that in mind, I'd say that if you find a doctor who has treated a dozen patients with Botox for axillary hyperhidrosis, they are most likely experienced enough.

Botox for the palms is trickier and more demanding skill-wise. There are fewer doctors out there who provide Botox injections for sweating of the hands (or feet, which are harder still). Because of this, I think it's appropriate to look for a physician with more experience. The same holds true when you're looking for a doctor to perform Botox injections for sweating on the head or face.

SweatSolutions:
Many readers ask whether Botox can be used to treat sweating in the groin area or sweating that occurs over large areas of the body. What's your expert opinion?

Dr. Pariser:
Botox is most effective at treating relatively small areas of skin, such as under the arms, on the palms, and on the forehead. Larger surface areas where people complain of sweating � such as in the groin or under the breasts � should perhaps be treated with topical products first. For instance we might try an aluminum chloride antiperspirant, either an over-the-counter or prescription variety, or we might try a moisture absorbing powder. If these don't work, Botox might be tried, but the limitation is the size of the area, the number of injections, and the amount of Botox needed to treat that area. I think this is a case when close consultation with an experienced physician would be critical.

SweatSolutions:
We have had readers say that Botox just didn't work for them and they continued to sweat after treatment. What would your response be to them?

Dr. Pariser:
If two weeks after your injections you're not very, very dry, my guess would be that during the injection process one or two key sweat-producing areas were missed. If I had a patient who told me that two weeks post-treatment he or she continued to sweat uncomfortably, I'd ask him or her to come back to my office and I would do a "starch iodine test". A starch iodine test is a simple way to see where exactly the sweat is coming from. Usually in a case like the one you've presented, a starch iodine test will reveal a spot, perhaps the size of a dime or smaller, that was not covered by the Botox injections. It's just one spot, but the sweat it is producing gets spread all over the armpit so it seems like the whole armpit is sweating. If I go back and inject in that one spot, that usually solves the problem.

If a physician is using 50 units of Botox per armpit there is much more of a chance that areas will be missed. I usually use 100 units of Botox per armpit. Of course, if a patient is paying out-of-pocket, he or she may prefer to try just 50 units per armpit, save some money, and see if it works. If this option is chosen, he or she should just be aware that there is a high probability that an area might be missed and a touch-up will be necessary. Some physicians also choose to inject only the hair-bearing area of the armpit, but there can be sweat glands outside of the hair that may be missed. I prefer to use a starch iodine test before any injections so I can see exactly where I need to treat. Before you have your Botox treatment, talk to your doctor about how touch-ups or missed areas will be handled in terms of fees.

SweatSolutions:
Final question (for now at least): Anything a person should do or not do to prepare for Botox injections?

Dr. Pariser:
Well, for the underarms, I'd say, don't shave. I don't like to inject cleanly shaven underarms. Allow for at least three or four days of stubble, even more is better.

In closing, I'd like to say that, in my office, nearly the entire staff is involved in helping to treat hyperhidrosis patients. And I think I can speak for all of us when I say that we get the most satisfaction out of helping our excessive sweating patients. The results, particularly with Botox, are so dramatic and the life changes that patients experience are truly heart warming. I hope that more physicians will choose to treat hyperhidrosis and get to see what I'm talking about. I encourage interested healthcare professionals to attend our upcoming continuing medical education programs in Philadelphia and Las Vegas. I'll be there and will be happy to answer questions.