When above-knee amputee Ann S. experienced excessive sweating in her socket and on her residual limb, she lost suction suspension and did not feel secure walking in her prosthesis. As a very active amputee, she didn’t want to be limited by down time to take off her socket, dry the sweat, only to have it return again in a short period.
“It was frustrating for her not to be able to wear her prosthesis as much as she wanted,” said Bill Sampson, CP.
So Bill offered his patient a unique solution - Botox® injections. While Botox, (onabotulinumtoxin A) is commonly thought of as “filler” for wrinkles, it is also used to treat excessive sweating (hyperhidrosis).
Bill referred his patient to Andrew H. Dubin, MD, a board certified physiatrist and an Associate Professor of PM&R at the Albany Medical College, with an office at The Bone and Joint Center. “I met with Dr. Dubin several months ago and learned that he has been using Botox on amputees to help reduce perspiration,” Bill said. “Given my patient’s activity goals and motivation to wear her prosthesis as much as possible, I felt she would be a good candidate for the treatment.”
“I have a very big problem with sweating,” Ann said. “I was in Virginia before my first treatment and my leg was falling off every day. I can’t describe how frustrating that was. I’ve been an amputee for 41 years, but the sweating problem has occurred as I’ve gotten older.”
Ann said the insecurity of not knowing how stable her prosthesis would be was ongoing. “I didn’t know when it would happen. I would just step off the curb and my leg would fly. And then I worried about sores because (the prosthesis) was moving and not in the right position. So I didn’t do as much as I would normally do because I was afraid.
“I was surprised when Bill told me about Botox because when you hear about Botox, you think of cosmetic procedures,” she said. “I was skeptical. But it’s working wonderfully. I had to go back to Virginia after receiving the injections and I had minimal problems. I did still have the sweating, but the humidity was 90 percent every day. Back in New York, I don’t have the problem at all.”
Dr. Dubin has been treating patients with Botox for residual limb hyperhidrosis for several years “Our patients are all similar in the demographics. They are very active, functional, typically K4 level amputees who are otherwise healthy but have failed occlusive roll-on sleeve management, have failed to get results from roll-on antiperspirants or aluminum chlorhydrate treatments in high concentrations,” Dr. Dubin said. “It’s common for amputees to experience sweating, but for some it is more of a problem than others. I find that many amputees won’t mention the issue because they are embarrassed. So what I do now is I ask them about it directly. They say, ‘I sweat like crazy, but I thought I was supposed to’” he said.
With the use of Botox injections, the patients experience relief from the sweat and problems associated with it. “Botox is a very powerful blocker of acetylcholine release which governs sweat gland activity , disabling the ability to sweat in the areas where the Botox has been injected,” Dr. Dubin said.
The procedure itself is simple and relatively painless. “The injections of botulinum toxin are done subcutaneously and intradermally with a tuberculin needle and a tuberculin syringe, so it’s no more uncomfortable than a tuberculin skin test,” Dr. Dubin explains. “We go around circumferentially the residual limb and administer about eight to 20 injections, depending on size of limb and area we have to cover. Generally within three to five to a maximum of seven days after they are injected, they notice a dramatic reduction in sweating.
“With Bill’s patient, I administered the Botox to approximately a dozen to 15 sites. She walked out and was good to go,” Dr. Dubin said.
“It’s working wonderfully. I feel more confident,” Ann said. “I still sweat, but I don’t have a pool of water in my leg anymore. I’m glad Bill knew about this and referred me to Dr. Dubin.”
Botox was approved as a treatment for axillary hyperhidrosis by the U.S. Food & Drug Administration in 2004.
Residual limb hyperhidrosis results both from the coverage of the residual limb by sockets and liners and from the relative increase of the perspiration caused by the decreased body surface. The result is decreased prosthesis function, particularly during warm periods, periods of strong professional activity or in sports activities.
Excessive sweating also contributes to skin breakdown and maceration due to the wet environment that the limb is in. Other unpleasant side effects include inflammation of the hair follicles, irritation, chafing and redness.
Botox is not only effective for amputees but for those who suffer from excessive sweating in the underarms, hands, feet, and face. There are no medical contraindications unless the patient has myasthenia gravis or an unusual neurological or neuromuscular disorder. Sometimes amputee patients report that it helps in relieving phantom limb pain.
Because Botox blocks the “chemical message” before it can enter the muscle, it is also used to treat spasticity, a condition commonly seen in those who have had a stroke, spinal cord injury, brain injury, or are living with cerebral palsy or multiple sclerosis. Spasticity typically affects the limbs and causes them to be tight.
“I use it very often for spasticity in children with CP; it helps with their walking,” Dr. Dubin said.” I also use it post stroke, spinal cord injury, and multiple sclerosis.”
Botox injections do not cure the spasticity or hyperhidrosis. Symptoms will usually appear again in about four to six months; then another application is required.
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