Stuart J. Salasche, MD Surgical Pearls Editor
Mark G. Lebwohl, MD Medical Pearls Editor
Jeffrey D. Bernhard, MD, and Jeremy S. Bordeaux, MD
Patientswithbrachioradialpruritus(BRP)often application may be counterproductive, but this
report that their itch feels ‘‘deep,’’ that scratch-
remains to be determined. There are anecdotal
ing only makes it worse, and that the only
reports that treatment with oral gabapentin may be
thing that provides any relief is the application of ice
helpful in treating some patients with severe BRP.
packs, chilling the skin to the point of numbness.The ice-pack sign is nearly pathognomonic for this
condition. The weight of available evidence suggests
1. Goodkin R, Wingard E, Bernhard JD. Brachioradial pruritus:
that BRP is a neurogenic/neuropathic itch.It usu-
Cervical spine disease and neurogenic/neuropathic pruritus. J Am Acad Dermatol 2003;48:521-4.
ally presents with a picking, prickling, burning, or
2. Cohen AD, Masaalha R, Medvedowvsky E, Vardy DA. Brachio-
just plain itchy itch of one or both forearms. BRP can
radial pruritus: A symptom of neuropathy. J Am Acad Dermatol
involve, or ‘‘spread,’’ to the upper arms as well
(especially the lateral aspects). It occasionally
3. Wallengren J, Sundler F. Brachioradial pruritus is associated with
spreads across the upper back, and very occasionally
a reduction in cutaneous innervation that normalizes during thesymptom-free remissions. J Am Acad Dermtol 2005;52:142-5.
across the neck and uppermost chest. In some
4. Winhoven SM, Coulson IH, Bottomley WW. Brachioradial pruri-
patients, sunlight acts as a trigger. Despite offering
tus: response to treatment with gabapentin. Br J Dermatol
temporary relief, it is also possible that ice-pack
From the Department of Dermatology, University of Massachusetts
ª 2005 by the American Academy of Dermatology, Inc.
Conflicts of interest: None identified.
Reprints not available from the authors.
Surgical Pearl: Use of needle-free anesthesia
From the Division of Dermatology, Department of Medicine,
Funding sources: Allergan Inc. provided editorial assistance.
Botulinum toxin type A (BTX-A) is a useful
treatment for palmar hyperhidrosis,espe-cially
However, palmar injection of BTX-A with a needle
Conflicts of interest: None identified.
is painful. The standard method of analgesia, nerve
Reprint requests and correspondence: Antranik Benohanian, MD,
Centre Hospitalier de l’Universite´ de Montre´al, 1058 Rue
block of the wrist, has potential drawbacks: vascular
puncture, impaired hand dexterity, and nerve scar-
ring from repeated injuries.Alternative analgesia
consists of a standard skin wheal of local anesthetic
raised on the palms with a needle, but it may also be
ª 2005 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2004.11.054
painful. Because jet injection of local anesthetic
Fig 1. Needle-free injector. The MED-JET MBX modelis produced by Medical International Technologies Inc
Fig 3. Minor bruising shown 24 hours after injections.
(Montreal, Quebec, Canada), a subsidiary of MedicalInternational Technology USA.
superficial skin wheals of lidocaine 2% over the en-tire palmar surface, 1.5 cm to 2 cm apart ). Theninject BTX-A with a 31-gauge needle. The metalcomponent of the MED-JET requires sterilization at1348C with an autoclave for 30 minutes; the plasticcomponent undergoes only cold sterilization.
Side effects include small bruises (of about 1 mm)
The cost of a MED-JET unit is $5000 (US). In conclusion, this technique has the potential to
replace peripheral nerve blockade prior to BTX-Ainjections for the treatment of palmar hyperhidrosis. It may also be used for plantar hyperhidrosis.
Fig 2. Lidocaine injection sites 1.5 cm to 2 cm apart.
reduces pain,needle-free lidocaine injections prior
REFERENCES1. Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver
to BTX-A injections (with a needle) are a reasonable
H, et al. Multi-Specialty Working Group on the Recognition,
option. (Reconstitution of BTX-A with lidocaine does
Diagnosis, and Treatment of Primary Focal Hyperhidrosis.
Recognition, diagnosis, and treatment of primary focal hyper-hidrosis. J Am Acad Dermatol 2004;51:274-86.
2. Hayton MJ, Stanley JK, Lowe NJ. A review of peripheral nerve
blockade as local anaesthesia in the treatment of palmar
The technique is easy to perform, quick, and well-
hyperhidrosis. Br J Dermatol 2003;149:447-51.
tolerated. Map out the BTX-A injection sites on the
3. Koenig HM, Paisansathan C, Albrecht RF 2nd, Zsigmond EK. Jet
palm. Prepare the needle-free injector (MED-JET;
injection of local anesthetic decreases pain of arterial cannula-
Medical International Technologies Canada, Montreal,
tion in awake neurosurgical patients. J Neurosurg Anesthesiol
4. Gassner HG, Sherris DA. Addition of an anesthetic agent to
per spurt to 0.02 mL (range, 0.01-0.1 mL) and adjust-
enhance the predictability of the effects of botulinum toxin
ing the pressure system so that the injection reaches
type A injections: A randomized controlled study. Mayo Clin
the desired depth. Use the MED-JET to produce
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