Electrical Stimulation in the Treatment of Pressure Injuries: A Systematic Review of Clinical Trials.

GENERAL PURPOSE: To provide information on evidence-based practice regarding the use of electrical stimulation for pressure injury management. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Apply clinical practice recommendations related to the use of electrical stimulation in the treatment of pressure injuries.2. Identify issues related to the use of electrical stimulation to treat pressure injuries.

To summarize evidence regarding the use of electrical stimulation for pressure injury (PI) management with a systematic review of randomized clinical trials. The authors searched scientific databases (PubMed, EBSCO, Medline, and Elsevier) and the online resources of gray publications for studies published between January 1, 1980, and June 20, 2021, using the keywords "electrostimulation," "electrical stimulation," "pressure ulcer," "pressure injury," "bedsore," and "decubitus ulcer." The search procedure generated 342 articles. Of these, 241 were disqualified after title screening, 52 after abstract screening, and 33 after full-text review; 16 articles were included in the review. Included articles were full-text reports of randomized clinical trials involving patients with PIs that had at least two patient groups, detailed how wounds healed, and were written in English. The authors extracted information about the purpose and design of each trial, patient inclusion and exclusion criteria, research methods, statistical analysis, findings, and conclusions. Researchers applied high-voltage monophasic pulsed current (HVMPC) in 10 trials, two trials used low-voltage monophasic pulsed current, three trials tested a low-voltage biphasic pulsed current, and one trial used low-intensity direct current. The effect of HVMPC in the treatment of PIs has been most thoroughly investigated in clinical trials. The results are consistent and indicate that HVMPC (twin-peak impulse, 50­154 µs, 100 pps, 45­60 min/d) is effective in PI treatment.

Pressure Injuries Treated With Anodal and Cathodal High-voltage Electrical Stimulation: the Effect on Blood Serum Concentration of Cytokines and Growth Factors in Patients With Neurological Injuries. A Randomized Clinical Study.

It remains unclear whether electrical currents can affect biological factors that determine chronic wound healing in humans. PURPOSE: The aim of this study was to determine whether anodal and cathodal high-voltage monophasic pulsed currents (HVMPC) provided to the area of a pressure injury (PI) change the blood level of cytokines (interleukin [IL]-1ß, IL-10, and tumor necrosis factor [TNF]-α) and growth factors (insulin-like growth factor [IGF]-1 and transforming growth factor [TGF]-ß1) in patients with neurological injuries and whether the level of circulatory cytokines and growth factors correlates with PI healing progression. METHODS: This study was part of a randomized clinical trial on the effects of HVMPC on PI healing. All patients with neurological injuries (spinal cord injury, ischemic stroke, and blunt trauma to the head) and a stage 2, stage 3, or stage 4 PI of at least 4 weeks' duration hospitalized in one rehabilitation center were eligible to participate if older than 18 years of age and willing to consent to donating blood samples. Exclusion criteria included local contraindications to electrical stimulation (cancer, electronic implants, osteomyelitis, tunneling, necrotic wounds), PIs requiring surgical intervention, patients with poorly controlled diabetes mellitus (HbA1C > 7%), critical wound infection, and/or allergies to standard wound treatment. Participants were randomly assigned to 1 of 3 groups: anodal (AG) or cathodal (CG) HVMPC treatment (154 µs; 100 Hz; 360 µC/sec; 1.08 C/day) or a placebo (PG, sham) applied for 50 minutes a day, 5 days per week, for 8 weeks. TNF-α, IL-1ß, IL-10, TGF-ß1, and IGF-1 levels in blood serum were assessed using the immunoenzyme method (ELISA) and by chemiluminescence, respectively, at baseline and week 4. Wound surface area measurements were obtained at baseline and week 4 and analyzed using a digitizer connected to a personal computer. Statistical analyses were performed using the maximum-likelihood chi-squared test, the analysis of variance Kruskal-Wallis test, the Kruskal-Wallis post-hoc test, and Spearman's rank order correlation; the level of significance was set at P ≤.05. RESULTS: Among the 43 participants, 15 were randomized to AG (mean age 53.87 ± 13.30 years), 13 to CG (mean age 51.08 ± 20.43 years), and 15 to PG treatment (mean age 51.20 ± 14.47 years). Most PIs were located in the sacral region (12, 74.42%) and were stage 3 (11, 67.44%). Wound surface area baseline size ranged from 1.00 cm2 to 58.04 cm2. At baseline, none of the variables were significantly different. After 4 weeks, the concentration of IL-10 decreased in all groups (AG: 9.8%, CG: 38.54%, PG: 27.42%), but the decrease was smaller in the AG than CG group (P = .0046). The ratio of pro-inflammatory IL-10 to anti-inflammatory TNF-α increased 27.29% in the AG and decreased 26.79% in the CG and 18.56% in the PG groups. Differences between AG and CG and AG and PG were significant (AG compared to CG, P = .0009; AG compared to PG, P = .0054). Other percentage changes in cytokine and growth factor concentration were not statistically significant between groups. In the AG, the decrease of TNF-α and IL-1ß concentrations correlated positively with the decrease of PI size (P <.05). CONCLUSION: Anodal HVMPC elevates IL-10/TNF-α in blood serum. The decrease of TNF-α and IL-1ß concentrations in blood serum correlates with a decrease of PI wound area. More research is needed to determine whether the changes induced by anodal HVMPC improve PI healing and to determine whether and how different electrical currents affect the activity of biological agents responsible for specific wound healing phases, both within wounds and in patients' blood. In clinical practice, anodal HVMPC should be used to increase the ratio of anti-inflammatory IL-10 to pro-inflammatory TNF-α , which may promote healing.

Efficacy of Biophysical Energies on Healing of Diabetic Skin Wounds in Cell Studies and Animal Experimental Models: A Systematic Review.

We have systematically assessed published cell studies and animal experimental reports on the efficacy of selected biophysical energies (BPEs) in the treatment of diabetic foot ulcers. These BPEs include electrical stimulation (ES), pulsed electromagnetic field (PEMF), extracorporeal shockwave (ECSW), photo energies and ultrasound (US). Databases searched included CINAHL, MEDLINE and PubMed from 1966 to 2018. Studies reviewed include animal and cell studies on treatment with BPEs compared with sham, control or other BPEs. Information regarding the objective measures of tissue healing and data was extracted. Eighty-two studies were eventually selected for the critical appraisal: five on PEMF, four each on ES and ECSW, sixty-six for photo energies, and three about US. Based on the percentage of original wound size affected by the BPEs, both PEMF and low-level laser therapy (LLL) demonstrated a significant clinical benefit compared to the control or sham treatment, whereas the effect of US did not reveal a significance. Our results indicate potential benefits of selected BPEs in diabetic wound management. However, due to the heterogeneity of the current clinical trials, comprehensive studies using well-designed trials are warranted to confirm the results.

A Randomized, Controlled Clinical Study to Assess the Effect of Anodal and Cathodal Electrical Stimulation on Periwound Skin Blood Flow and Pressure Ulcer Size Reduction in Persons with Neurological Injuries.

The use of electrical stimulation (ES) should be considered for treating nonhealing pressure ulcers (PUs), but optimal ES wound treatment protocols have yet to be established. A randomized, controlled, double-blind clinical study was conducted to evaluate the effects of cathodal and anodal high-voltage monophasic pulsed current (HVMPC) on periwound skin blood flow (PSBF) and size reduction of Stage 2 to Stage 4 PUs of at least 4 weeks' duration. Persons >18 years of age, hospitalized with neurological injuries, at high risk for PU development (Norton scale <14 points; Waterlow scale >15 points), and with at least 1 Stage 2 to Stage 4 PU were eligible to participate in the study. Persons with necrotic wounds, osteomyelitis, electronic or metal implants in the PU area, PUs in need of surgical intervention, acute wound inflammation, diabetes (HBA1c >7%), diabetic neuropathy, cancer, and/or allergies to standard wound treatments were excluded. Patients were randomly assigned to 1 of 3 groups: anodal (AG), cathodal (CG), or placebo (PG) ES. All groups received individualized PU prevention and standard wound care. In the PG, sham ES was applied; the AG and CG were treated with anodal and cathodal HVMPC, respectively (154 µs 100 Hz; 360 µC/second; 1.08 C/day), 50 minutes per day, 5 days per week, for a maximum of 8 weeks. PSBF was measured using laser Doppler flowmetry at baseline, week 2, and week 4, and wound surface area measurements were obtained and analyzed using a digitizer connected to a personal computer. Data analysis utilized the maximum-likelihood chi-squared test, the analysis of variance Kruskal-Wallis test, the Kruskal-Wallis post-hoc test, and Spearman's rank order correlation. Nonlinear approximation based on exponential function was used to calculate treatment time needed to reduce the wound area by 50%. In all tests, the level of significance was set at P ≤.05. Of the 61 participating patients, 20 were in the AG (mean age 53.2 ± 13.82 years), 21 in the CG (mean age 55.67 ± 17.83 years), and 20 in the PG (mean age 52.5 ± 13.18 years). PUs (baseline size range 1.01 cm2 to 59.57 cm2; duration 4 to 48 weeks) were most frequently located in the sacral region (73.77%) and classified as Stage 3 (62.29%). PSBF at week 2 was significantly higher in the AG and CG than in the PG (P <.05). Week 4 differences were not statistically significant. Wound percentage area reduction calculated at week 8 for the AG (64.10% ± 29.22%) and CG (74.06% ± 23.23%) were significantly different from PG ulcers (41.42% ± 27.88%; P = .0391 and P = .0024, respectively). In both ES groups, PSBF at week 4 and percent wound surface area reductions between weeks 4 and 8 were positively correlated, but only the AG correlation was statistically significant (P = .049). In this study, both ES modalities improved blood flow and wound area reduction rate. Studies examining optimal ES treatment times for healing to occur, the effect of comorbidities and baseline wound variables on ES outcomes, and the nature of the relationship between blood flow and healing are necessary.

The Efficacy of Pressure Ulcer Treatment With Cathodal and Cathodal-Anodal High-Voltage Monophasic Pulsed Current: A Prospective, Randomized, Controlled Clinical Trial.

BACKGROUND: Studies show that anode and cathode electrical stimulation (ES) promotes the healing of wounds, but specific protocols for both electrodes are not available. OBJECTIVE: To compare the effectiveness of cathodal versus cathodal+anodal ES in the treatment of Category II-IV pressure ulcers (PrUs). DESIGN: Prospective, randomized, controlled, clinical study. SETTING: Three nursing and care centers. PATIENTS: Sixty-three participants with PrUs were randomly formed into a cathodal ES group (CG: N = 23; mean age of 79.35; SD 8.48), a cathodal+anodal ES group (CAG: N = 20; mean age of 79.65; SD 11.44) and a placebo ES group (PG: N = 20; mean age of 76.75; SD 12.24). INTERVENTION: All patients were treated with standard wound care and high-voltage monophasic pulsed current (HVMPC; twin-peak impulses; 154 µs; 100 pps; 0.25 A; 250 µC/s) for 50 minutes per day, 5 times a week, for 6 weeks. The CG, CAG, and PG received, respectively, cathodal, cathodal+anodal, and sham ES through electrodes placed on a moist gauze pad. The treatment electrode was placed on the wound, and the return electrode was positioned on healthy skin at least 20 cm from the PrU. MEASUREMENTS: Measurements were made at baseline, and after each of the 6 weeks of treatment. Primary outcome was percentage wound surface area reduction at week 6. RESULTS: Wound surface area decreased in the CG by 82.34% (95% confidence interval [CI] 70.06-94.63) and in the CAG by 70.77% (95% CI 53.51-88.04). These reductions were significantly greater than in the PG (40.53%; 95% CI 23.60-57.46). The CG and CAG were not statistically significantly different regarding treatment results. LIMITATIONS: The time of treatment proved insufficient for PrUs to close. CONCLUSIONS: Cathodal and cathodal+anodal HVMPC similarly reduced the area of Category II-IV PrUs.

Evaluation of the Healing Progress of Pressure Ulcers Treated with Cathodal High-Voltage Monophasic Pulsed Current: Results of a Prospective, Double-blind, Randomized Clinical Trial.

OBJECTIVE: To investigate the effectiveness of high-voltage monophasic pulsed current (HVMPC) as an adjunct to a standard wound care for the treatment of Stage II and III pressure ulcers (PrUs). DESIGN: Prospective, randomized, double-blind, controlled clinical study. SETTING: Two nursing and care centers. PATIENTS: Patients with PrUs that did not respond to previous treatment for at least 4 weeks were randomly assigned to the electrical stimulation (ES) group (25 patients; mean age of 79.92 ± 8.50 years; mean wound surface area [WSA] of 10.58 ± 10.57 cm) or to the control group (24 patients; mean age of 76.33 ± 12.74 years; mean WSA of 9.71 ± 6.70 cm). INTERVENTIONS: Both the ES and control groups received standard wound care and respectively, cathodal HVMPC (154 microseconds; 100 pulses per second; 0.24 A; 250 µ/s) applied continuously for 50 minutes once a day, 5 times a week, or sham HVMPC. MAIN OUTCOME: Percentage area reduction over 6 weeks of intervention. MAIN RESULTS: In the ES group, there was a statistically significant decrease in WSA after 1 week of treatment (35% ± 30.5%) compared with 17.07% ± 34.13% in the control group (P = .032). After treatment, at week 6, percentage area reduction in the ES group was 80.31% ± 29.02% versus 54.65% ± 42.65% in the control group (P = .046). CONCLUSIONS: Cathodal HVMPC reduces the WSA of Stage II and III PrUs. The results are consistent with the results of other researchers who used HVMPC to treat PrUs.

Electrical Stimulation Technologies for Wound Healing.

Objective: To discuss the physiological bases for using exogenously applied electric field (EF) energy to enhance wound healing with conductive electrical stimulation (ES) devices. Approach: To describe the types of electrical currents that have been reported to enhance chronic wound-healing rate and closure. Results: Commercial ES devices that generate direct current (DC), and mono and biphasic pulsed current waveforms represent the principal ES technologies which are reported to enhance wound healing. Innovation: Wafer-thin, disposable ES technologies (wound dressings) that utilize mini or micro-batteries to deliver low-level DC for wound healing and antibacterial wound-treatment purposes are commercially available. Microfluidic wound-healing chips are currently being used with greater accuracy to investigate the EF effects on cellular electrotaxis. Conclusion: Numerous clinical trials described in subsequent sections of this issue have demonstrated that ES used adjunctively with standard wound care (SWC), enhances wound healing rate faster than SWC alone.

Chitosan-cellulose composite for wound dressing material. Part 2. Antimicrobial activity, blood absorption ability, and biocompatibility.

Chitosan (CS), a polysaccharide derived from chitin, the second most abundant polysaccharide, is widely used in the medical world because of its natural and nontoxic properties and its innate ability for antibacterial and hemostasis effects. In this study, the novel composites containing CS and cellulose (CEL) (i.e., [CEL + CS]), which we have previously synthesized using a green and totally recyclable method, were investigated for their antimicrobial activity, absorption of anticoagulated whole blood, anti-inflammatory activity through the reduction of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), and the biocompatibility with human fibroblasts. The [CEL + CS] composites were found to inhibit the growth of both Gram positive and negative micro-organisms. For examples, the regenerated 100% lyophilized chitosan material was found to reduce growth of Escherichia coli (ATCC 8739 and vancomycin resistant Enterococcus faecalis (ATCC 51299) by 78, 36, and 64%, respectively. The composites are nontoxic to fibroblasts; that is, fibroblasts, which are critical to the formation of connective tissue matrix were found to grow and proliferate in the presence of the composites. They effectively absorb blood, and at the same rate and volume as commercially available wound dressings. The composites, in both air-dried and lyophilized forms, significantly inhibit the production of TNF-α and IL-6 by stimulated macrophages. These results clearly indicate that the biodegradable, biocompatible and nontoxic [CEL + CS] composites, particularly those dried by lyophilizing, can be effectively used as a material in wound dressings.

Skin cell proliferation stimulated by microneedles.

A classical wound may be defined as a disruption of tissue integrity. Wounds, caused by trauma from accidents or surgery, that close via secondary intention rely on the biological phases of healing, i.e., hemostasis, inflammation, proliferation, and remodeling (HIPR). Depending on the wound type and severity, the inflammation phase begins immediately after injury and may last for an average of 7-14 days. Concurrent with the inflammation phase or slightly delayed, cell proliferation is stimulated followed by the activation of the remodeling (maturation) phase. The latter phase can last as long as 1 year or more, and the final healed state is represented by a scar tissue, a cross-linked collagen formation that usually aligns collagen fibers in a single direction. One may assume that skin microneedling that involves the use of dozens or as many as 200 needles that limit penetration to 1.5 mm over 1 cm(2) of skin would cause trauma and bleeding followed by the classical HIPR. However, this is not the case or at least the HIPR phases are significantly curtailed and healing never ends in a scar formation. Conversely dermabrasion used in aesthetic medicine for improving skin quality is based on "ablation" (destruction or wounding of superficial skin layers), which requires several weeks for healing that involves formation of new skin layers. Such procedures provoke an acute inflammatory response. We believe that a less intense inflammatory response occurs following microneedle perforation of the skin. However, the mechanism of action of microneedling appears to be different. Here we review the potential mechanisms by which microneedling of the skin facilitates skin repair without scarring after the treatment of superficial burns, acne, hyperpigmentation, and the non-advancing periwound skin surrounding the chronic ulcerations of the integument.

The hypothesis of 'biophysical matrix contraction': wound contraction revisited.

Wound contraction is an orchestrated phenomenon that contributes to closure of wounds that heal by secondary intention. However, excessive and premature contraction results in scarring. Although the exact mechanism of contraction is unknown, the wound closure process is accompanied by and followed by changes in the physical and mechanical properties of the wound and periwound tissues during the biological transformation. Transforming growth factor-beta (TGF-beta) induces a contractile phenotype in the cellular-extracellular matrix. Meanwhile, various external and internal mechanical stresses lead to microdeformations of the wound milieu with resultant upregulation of TGF-beta. Furthermore, the mechanical strain exerted on collagen fibres and other piezoelectric tissues leads to development of piezoelectric current in the wound site, which acts synergistically with TGF-beta. TGF-beta and mechanical strain regulate the orientation of collagen fibres parallel with the skin surface, which minimises the induction of piezoelectricity through the action of internal forces because of improper angulation of collagen fibres and these forces. The resulting dominance of external forces guides the contractile activity towards restoration of the original unwounded tissue architecture and functional activity of the previously wounded milieu. The aforementioned contractile activity proceeds into the remodelling phase of wound healing as the level of TGF-beta is reduced and myofibroblasts undergo apoptosis.

Superficial topography of wound: a determinant of underlying biological events?

Three-dimensional configuration of wounds varies considerably according to the etiology. Wounding of skin is proceeded by release of dermal pretension. Subsequent disruption of physical equilibrium with resulting development of force vectors alters the primary shape of wound to maintain a new dynamic physical equilibrium. This leads to the development of stress-relaxation and stress-concentration areas throughout the wound milieu. Mechanical strain produces piezoelectric current which is maximal in stress-relaxation regions due to lower tissue stiffness and higher mobility. Early surge in the tissue level of TGF-beta would be exaggerated through synergistic interaction with piezoelectric current in stress-relaxation areas. Subsequently, fibroblasts migrate to these areas due to galvanotaxis. The gradual dissipation of tissue tension, due to irreversible loss of viscous strain, reduces the synergistic action of TGF-beta and piezoelectricity. However, a similar pattern of activity of TGF-beta due to the polarized migration of fibroblasts, which are the main source of TGF-beta during secondary surge, may be continued. It seems that a biological-mechanical continuum exists for wounds so that even the superficial topography of wounds may affect the underlying biological activity and final healing outcome during healing of dermal wounds.

Antibacterial activity of positive and negative polarity low-voltage pulsed current (LVPC) on six typical Gram-positive and Gram-negative bacterial pathogens of chronic wounds.

The positive effect of electrical stimulation (ES) on wound healing has been shown in vitro and in vivo. On the basis of increased blood flow, protein denaturation, and stimulation of cellular defense, an antibacterial effect of ES is to be expected. Although the antibacterial effect of ES already has been demonstrated in vitro, little attention has been paid to the direct antibacterial effect of changing polarity of the applied current. The aim of this study was to investigate the antibacterial effect of positive and negative monophasic low-voltage pulsed current on typical Gram-positive and Gram-negative pathogens of chronic wounds. Using the Dermapulse-System, three Gram-negative (Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae) and three Gram-positive (Staphylococcus aureus, Staphylococcus epidermidis, Escherichia faecium) organisms were tested against positive and negative polarity low voltage pulsed current. All tested organisms were significantly reduced by ES. The reduction differed significantly between positive polarity and control and negative polarity and control, with the highest log10 reduction factor (RF) achieved with positive polarity. Using positive polarity, the maximum RF was measured for E. coli (median log10 RF 0.83; 25th percentile 0.59, 75th percentile 0.98) and the lowest for S. epidermidis (median log10 RF 0.20; 25th percentile 0.17, 75th percentile 0.24). Yet, there was no significant difference with positive ES against Gram-positive or Gram-negative organisms.

Bactericidal and cytotoxic effects of chloramine-T on wound pathogens and human fibroblasts in vitro.

OBJECTIVES: To evaluate cytotoxicity and bactericidal effects of chloramine-T. METHODS: In vitro study of various concentrations and exposure times to preparations containing human fibroblasts or 1.5 x 10 colony forming units per milliliter (CFU/mL) of 3 gram-positive bacteria-Staphylococcus aureus, methicillin-resistant S aureus, and vancomycin-resistant Enterococcus faecalis-and 2 gram-negative bacteria-Escherichia coli and Pseudomonas aeruginosa-with and without fetal bovine serum present. MAIN OUTCOME MEASURES: Percentage reduction of bacterial growth and percentage of viable fibroblasts 48 hours after exposure. RESULTS: All gram-positive growth was reduced by 95% to 100%, regardless of dose, with or without serum. E coli (gram-negative; with/without serum) was reduced 94% to 100% at antiseptic concentrations of 300 and 400 ppm. At 200 ppm, E coli growth was fully inhibited without serum present and by 50% with serum. P aeruginosa (gram-negative) was not significantly affected under any conditions. At 100 and 200 ppm, cell viability remained greater than 90% under all experimental conditions. A 300-ppm, 3-minute exposure to chloramine-T resulted in cell viability of up to 70%, with longer exposures producing lower viabilities. Serum did not affect cell viability in any condition. CONCLUSIONS: In vitro, chloramine-T at 200 ppm for 5 to 20 minutes was effective against 3 virulent gram-positive bacteria without fibroblast damage. At 300 ppm and 3 and 5 minutes, 30% of fibroblasts were damaged and 95% to 100 % of E coli were inhibited, respectively.

Electrical stimulation for wound healing: a review of evidence from in vitro studies, animal experiments, and clinical trials.

This article reviews theories linked to endogenous bioelectric currents and the role they may play in wound repair with further appraisal of in vitro and in vivo research related to the effects of clinically applicable electrical currents on protein synthesis, cell migration, and antibacterial outcomes. In addition, studies on the effects of electrical stimulation (ES) on skin grafts, donor sites, and musculocutaneous flaps in animals are evaluated, as well as assessments of numerous clinical reports that examined the effects of ES on angiogenesis, perfusion, PtcO2, and epithelialization. Finally, a plethora of clinical trials related to the responses of chronic lower extremity wounds to ES therapy are reviewed, with emphasis on wounds caused by venous insufficiency, diabetic neuropathy, and ischemia in patients with and without diabetes mellitus. A glossary that addresses ES terminology is also included.

Management of postsurgical hyperhidrosis with direct current and tap water.

BACKGROUND AND PURPOSE: Excessive sweating, known as hyperhidrosis, involves the eccrine sweat glands of the axillae, soles, palms, and/or forehead. The use of iontophoresis to reduce or eliminate excessive sweating has been described since 1952. The purpose of this case report is to describe the use of tap water galvanism (TWG) using direct current (DC) with a patient who had postsurgical hyperhidrosis. CASE DESCRIPTION: The patient was a 36-year-old male electrician with traumatic phalangeal amputation and postsurgical development of hyperhidrosis. Tap water galvanism was administered using a DC generator, 2 to 3 times per week for 10 treatments. The patient's hands were individually submerged in 2 containers of tap water with the electrodes immersed directly into the containers. Each hand was treated with 30 minutes of TWG at 12 mA. Hyperhidrosis was measured by a 5-second imprint and subsequent tracing of the left hand placed on dry paper toweling. OUTCOMES: The patient's hyperhidrosis decreased from the full left palmar pad, with a surface area of 10.3x12.0 cm, to a reduced area of wetness that covered a 2.2-x2.7-cm area. The patient returned to work as an electrician without needing absorbent gloves, which had prevented him from performing electrical work. DISCUSSION: Following use of TWG, the patient's palmar hyperhidrosis returned to normhidrosis.