the united states department of defense and department of veteran affairs are dedicated to providing superior rehabilitation care for veterans and service members who have suffered combat - associated traumatic limb loss .
current literature reports that 70% of amputees with multiple limb loss are bothered by sweating and skin irritation inside of the prosthesis socket .
we present a review of the literature examining the effectiveness of botulinum toxin a ( btx - a ) and btx - b for the treatment of hyperhidrosis related to prosthesis use .
while both btx - a and btx - b are approved by the food and drug administration ( fda ) , indications for use are limited .
hyperhidrosis continues to be a significant barrier to prosthesis comfort , and treatment with btx has the potential to address this concern .
a review of the literature was conducted using the pubmed database , focusing on hyperhidrosis treatment after a traumatic limb amputation .
we used the key search words : btx ; hyperhidrosis ; amputation ; trauma - related amputation ; prosthesis comfort .
articles discussing hyperhidrosis treatment for axillary , palmar , plantar and amputations secondary to chronic medical conditions were excluded .
botulinum toxin a is currently approved by the fda as botox ( allergan , inc . ,
irvine , california , usa ) supplied in 50 and 100 unit vials , and dysport ( ipsen , berkshire , united kingdom ) supplied in 300 and 500 unit vials , to treat cervical dystonia , severe primary axillary hyperhidrosis , strabismus , blepharospasm , and for temporary improvement of moderate to severe glabellar lines .
the benefits of using btx - a for these conditions is well - established and it has few adverse effects at their respective therapeutic doses , which range from 20 to 360 units .
the most common adverse effects reported are muscle weakness , fatigue , flu - like symptoms , dry mouth , dizziness , discomfort at the injection site and skin rash
. large volume injections of btx - a > 600 units have been associated with systemic weakness related to injection dose and frequency , which should be a consideration in the treatment of the residual limb hyperhidrosis .
current literature emphasizes the positive effects of btx - a on pain perception , itch and inflammation while simultaneously producing an anhidrotic effect . a study conducted by charrow et al
. found that injections of btx - a successfully reduced residual limb hyperhidrosis and improved prosthesis fit and function when evaluated three weeks after treatment . in this study , 300 - 500 units of btx - a at a dilution of 100 units in 1 ml of 0.9% isotonic saline were injected intradermally with 2 - 3 units at 1 cm intervals in a circumferential pattern on the skin covered by the prosthesis socket .
this approach however , did not have any effect on the residual limb pain ( rlp ) or phantom limb pain ( plp ) .
however , jin et al . demonstrated in three cases that injection of btx - a at 200 , 300 , or 500 units using electromyographic guidance and targeting areas of the residual limb where strong fasciculations were present achieved marked improvement in rlp and plp lasting up to three months .
three separate case studies utilized a starch - iodine test to identify hyperhidrotic areas on a residual limb , then injected btx - a at 100 u in 5 - 10 unit aliquots , or 300 units in 25 units aliquots .
in all three reports , btx - a was diluted in preservative - free saline and produced anhidrotic effects lasting three months .
because our facility is a government - funded hospital with extensive medical coverage for military personnel , poor prosthesis satisfaction due to hyperhidrosis is the only indication needed for treatment . while large volume injections can be costly
, the literature has shown that improving prosthesis comfort is directly correlated with an improved quality of life .
to inject btx - a at 1 - 2 cm intervals in a grid - like pattern over a surface area of 600 cm would require over 140 intradermal injections , typically achieved with a 30-gauge needle .
the procedure lasts up to 30 min and is criticized as painful . a recent study by torrisi et al . investigated the use of pocketed microneedles ( pmn ) as an intradermal delivery system for btx - a .
the width of the pmn used in this study is 340 m , which could serve as a less invasive administration method of btx - a in hyperhidrotic areas .
botulinum toxin type b , supplied in 2500 , 5000 , and 10,000 units vials is approved by the fda as myobloc ( solstice neurosciences , inc .
the use of btx - b for the treatment of palmar hyperhidrosis was deemed effective by baumann et al . and further studied by kern et al . in the treatment of the residual limb hyperhidrosis for lower limb amputees .
btx - b administered in a low dose is believed to have a higher affinity for sympathetic nerve endings and better diffusion than btx - a .
furthermore , btx - b and was found to be effective in reducing residual limb sweating in nine lower limb amputees .
treated nine lower limb amputees with 1750 units of btx - b injected intracutaneously using a 27-gauge needle ( 20 injection sites 2 - 4 cm apart ) .
in addition to subjective identification of hyperhidrotic areas , a starch - iodine test was used on six participants , to help guide injection locations .
study reported a significant reduction in residual limb sweating and a significant improvement in use of the prosthetic device , duration of use and quality of life evaluated 4 weeks and 3 months after treatment .
btx - b also decreased rlp and plp as well as improved quality of life and prosthesis use .
reports that btx - b injections in muscular trigger points decreased rlp and involuntary movements of the stump for 4 - 12 weeks , which was dependent on the btx - b dose and location of amputation .
two of the four patients had a trauma - related amputation , and all found the injections very painful .
current literature investigating the use of btx to treat hyperhidrosis in trauma - related amputations is limited .
however , current case studies all report positive outcomes related to treating hyperhidrosis with either btx - a or btx - b .
hyperhidrosis , discomfort , and skin irritation related to prosthesis use in trauma - related limb loss remains a topic deserving of more attention as a larger , double - blind , placebo - controlled study evaluating the efficacy of btx - a and btx - b in treatment .
 hyperhidrosis - related to prosthesis use in patients who have suffered a traumatic limb amputation presents itself as a barrier to comfort , prosthesis use and overall quality of life . 
 this review intends to encourage dermatologists to consider the use of botulinum toxin a or b for the treatment of hyperhidrosis in the residual limb and may serve as a stimulus for a modern , in - depth , and more comprehensive study . 
 a review of the literature was conducted using the pubmed database , focusing on hyperhidrosis treatment after traumatic limb amputation . 
 articles discussing hyperhidrosis treatment for amputations secondary to chronic medical conditions were excluded . 
 seven case studies published over the last 12 years have demonstrated positive outcomes of this treatment strategy . 
 overall , there is little data examining this topic and current publications focus primarily on small case series . 
 a larger , double - blind , placebo - controlled study would likely benefit veterans , service members , and civilians . 
INTRODUCTION
BOTULINUM TOXIN A
BOTULINUM TOXIN B
CONCLUSION