Delivery of Botox�� by iontophoresis: replyfrom authors

DOI: 10.1111/j.1365-2133.2005.06916.x

SIR, We thank Dr Solomon for taking the time and interest to

write after reading our article.1 He clearly has considerable

expertise in injecting Botox under regional anaesthesia, and

the few cases I have done have been performed using a Bier

block (performed by one of our anaesthetists). We are gener-

ally funded in our hospital to do axillae only, hence our lim-

ited experience of injecting palms. It was one of our patient’s

comments that she had paraesthesia lasting a couple of days

that prompted me to think of alternative methods of Botox

delivery. We agree that ice is ineffective and barbaric.

The comment that Botox injection ‘invariably causes a tran-

sient weakness of small hand muscles’ was based on our read-

ing of the literature2 and on verbal communications from

colleagues, but we are pleased to be corrected if we oversta-

ted. The cost of Botox in the U.K. at present is not inexpen-

sive at £130 ($260) per 100 IU for National Health Service

hospital practitioners. What is more expensive, however, is

the anaesthetist’s time, although there are some dermatologists

who perform their own regional block.3 We have not under-

taken to learn the technique until our hospital approves fund-

ing for such patients, and there has been some concern that

repeated injection of regional nerves may be damaging.4 The

technique described by Dr Solomon obviates that risk, and

indeed, intravenous regional anaesthesia for the same indica-

tion was brought to attention in the correspondence section

of this Journal a few years ago.5 We appreciate that the

method of applying a small tourniquet to the wrist, while

using a small dose of lignocaine, allows the tourniquet to be

let down over 5 min after injections, without fear of a rapid

infusion of a large dose of lignocaine.

Finally, we believe that novel methods of painless drug

delivery are worth testing, and should we manage to get this

method to work easily, one could envisage a role for nurse-

led Botox iontophoresis, as is currently in use for tap water or

glycopyrrolate.

Department of Dermatology,

The Royal Infirmary of Edinburgh,

Edinburgh EH3 9YW, U.K., and

*College of Medicine and Veterinary Sciences,

University of Edinburgh, Edinburgh, U.K.

E-mail: gina.kavanagh@luht.scot.nhs.uk

G.M. KAVANAGH

K . SHAMS*

References

1 Kavanagh GM, Oh C, Shams K. BOTOX� delivery by iontophoresis.Br J Dermatol 2004; 151:1093–5.

2 Schnider P, Moraru E, Kittler H et al. Treatment of focal hyperhidro-sis with botulinum toxin type A: long-term follow-up in 61

patients. Br J Dermatol 2001; 145:289–93.

3 Hayton MJ, Stanley JK, Lowe NJ. A review of peripheral nerveblockade as local anaesthesia in the treatment of palmar hyperhidro-

sis. Br J Dermatol 2003; 149:447–51.4 Gelander D, Dhuner K, Lundborg G. Peripheral nerve injury due to

injection needles used for regional anaesthesia. Acta Anaesth Scand1977; 21:182–8.

5 Vollert B. Intravenous regional anaesthesia for treatment of palmarhyperhidrosis with botulinum toxin type A. Br J Dermatol 2001;

144:632–3.

Conflict of interest: none declared.

Five cases of cutaneous leishmaniasis inCambridge, U.K.

DOI: 10.1111/j.1365-2133.2005.06921.x

SIR, We describe five cases of cutaneous leishmaniasis (CL)

presenting within a year (2002–2003) to a single U.K. derma-

tology department.

Patient 1 was a 50-year-old woman with an asymptomatic

9-mm erythematous, keratotic nodule on her right cheek

(Fig. 1a) appearing 18 months after returning from holiday

in Egypt and a year after a holiday in Spain. Biopsy of the

nodule showed dermal granulomatous inflammation com-

posed of lymphocytes, plasma cells and parasitized histiocytes

suggestive of leishmaniasis. Using polymerase chain reaction

(PCR),1 Leishmania donovani complex DNA was detected in a

slit-skin smear. The nodule resolved completely following a

single treatment using 0Æ5 mL of sodium stibogluconate

injected in a quadratic around the lesion with a 21-gauge

needle.

Patient 2 was a 23-year-old paratrooper who developed a

painless nonhealing leg ulcer (Fig. 1b) 2 months after being

bitten by sandflies during his jungle training in Belize.

Examination revealed a shallow ulcer with an irregular edge

on the left medial malleolus. Serology and tissue culture for

Leishmania were negative. Biopsy showed a noncaseating gra-

nulomatous giant cell infiltrate in the deep dermis and

subcutis. Leishmania (Viannia) brasiliensis complex DNA was

detected using PCR technology. He was admitted to the

Hospital for Tropical Diseases in London and was treated

with intravenous sodium stibogluconate 20 mg kg)1 daily

for 20 days. The ulcer had clinically improved at the time

of discharge.

Patient 3 was a 31-year-old woman who injured her knee

during a holiday in Central America in February 2002. For-

eign bodies were embedded in the laceration but were

picked out immediately. The wound healed over a couple of

weeks to form a purplish tender hypertrophic scar (Fig. 1c).

Biopsy revealed scar tissue with prominent vessels and scat-

tered histiocytes. Culture for Leishmania parasites was negative.

Leishmania mexicana complex DNA was detected using PCR

� 2005 British Association of Dermatologists • British Journal of Dermatology 2005 153, pp1067–1092

1076 Correspondence