A preliminary study of painless and effective transdermal botulinum toxin A delivery by jet nebulization for treatment of primary hyperhidrosis

Background: Hyperhidrosis is a chronic disease characterized by increased sweat production. Local injections of botulinum toxin A (BTX-A) have been extensively used for treatment of primary hyperhidrosis (idiopathic). The current treatment for this condition involves several intradermal injections, resulting in poor patient compliance due to injection-related pain. Therefore, new protocols, including an improved anesthetic regimen, are required. Aim: We designed the present study to determine whether JetPeel (TM)-3, a medical device used for transdermal delivery of drugs by jet nebulization, could be used to deliver lidocaine prior to the standard multiple BTX-A injections or deliver lidocaine together with BTX-A in order to determine the protocol giving better results in terms of procedure-related pain, sweating, and patient satisfaction in subjects affected by primary axillary, palmar or plantar hyperhidrosis. Materials and methods: Twenty patients with a visual analog scale (VAS) sweating score >= 8 cm were randomized to receive lidocaine 2% (5 mL) delivered by JetPeel (TM)-3 followed by multiple injections of BTX-A (100 units) or lidocaine 2% (5 mL) and BTX-A (50 units) delivered together by JetPeel (TM)-3. Effect of treatment on sweating was measured by VAS (0= minimum sweating; 10= maximum sweating) at 3-month follow-up. Pain induced by the procedure was assessed by VAS (0= minimum pain; 10= maximum pain) immediately after the procedure. Patient satisfaction was assessed at 3-month follow-up using a 5-point scale (1= not at all satisfied; 2= not satisfied; 3= partially satisfied; 4= satisfied; 5= highly satisfied). Results: Both treatment modalities reduced sweating at 3-month follow-up, if compared with baseline (all P < 0.001). Delivery of lidocaine and BTX-A by JetPeel (TM)-3 resulted in lower procedure-related pain and reduced sweating, if compared with lidocaine delivered by JetPeel (TM)-3 followed by multiple BTX-A injections (all P < 0.001). Patient satisfaction with the procedure was higher in the group receiving lidocaine and BTX-A treatment by JetPeel (TM)-3, if compared with lidocaine delivered by JetPeel (TM)-3 followed by multiple BTX-A injections (P < 0.001). No side effects were observed in both groups. Conclusion: Lidocaine and BTX-A can be safely delivered together by JetPeel (TM)-3 to treat primary palmar, plantar and axillary hyperhidrosis, resulting in lower procedure-related pain, improved sweating and higher patient satisfaction, if compared with lidocaine delivered by JetPeel (TM)-3 followed by standard BTX-A injection therapy. Our protocol delivering lidocaine and BTX-A together by JetPeel (TM)-3 requires a reduced quantity of BTX-A, further supporting the use of the transdermal drug delivery by jet nebulization over standard injection therapy for treatment of primary hyperhidrosis.