Carry out intradermal injections of botulinum toxin type A to treat cosmetic excessive sweating

This standard coexists alongside, SKANSC*1.2:* Implement and maintain safe, hygienic and effective working practices during elective non-surgical cosmetic procedures and SKANSC*2.2: Consult, assess, plan and prepare for elective non-surgical cosmetic procedures within the working environment*, following a consultation and evaluation with a regulated independent prescriber. This standard is for aesthetic practitioners carrying out intradermal injections of botulinum toxin type A to treat cosmetic excessive sweating. The botulinum type A inhibits the release of acetylcholine, a neurotransmitter of the parasympathetic nervous system, preventing the hyper stimulation of eccrine sweat glands that leads to excessive sweating. Botulinum toxin is performed as a course of procedures as the nerves will regenerate over time. You will also be required to do a post procedure evaluation and reflection for continuous improvement. The aesthetic practitioner must have a First Aid at Work qualification or equivalent and be able to carry out the functions within SFHCHS36: Basic life support and have access to life support equipment as identified in the emergency plan. Users of this standard will need to ensure that their practices reflect up-to-date information, policies, procedures and best practice guidance.

The main outcomes are :

1. Reduce cosmetic excessive sweating
2. To treat diagnosed primary focal axillary hyperhidrosis

1. acquire and discuss the individual’s consultation outcomes and documentation for the botulinum toxin type A procedure from the regulated independent prescriber, to include:

1.1 individual procedure plan to include areas to be treated 

1.2 advice, support and guidance

1.3 emergency plan

1.4 medicine management policy

1.5 pain management strategy

2. agree and obtain the botulinum toxin type A prescription from the regulated independent prescriber, in accordance with the botulinum toxin type A procedure protoco*l*, legislative, regulatory requirements, organisational policies and procedures

3. carry out a concise and comprehensive consultation face to face with the individual and maintain your responsibilities for health and safety pre, during and post the botulinum toxin type A procedure

4. discuss the individual’s objectives, concerns, expectations and desired outcomes to inform the botulinum toxin type A procedure plan, to include:

4.1 alternative treatment options

5. establish the botulinum toxin type A procedure plan in accordance with legislative requirements and organisational policies and procedures

6. reiterate, confirm and agree with the individual, they have understood the proposed botulinum toxin type A procedure and pain management, to include:

6.1 contra-actions

6.2 adverse reactions

7. obtain and record the individual’s informed consent for the botulinum toxin type A procedure and pain management, allowing an adequate time scale for the individual to make an informed choice 

8. review the informed consent for the botulinum toxin type A procedure and pain management

9. collect with the individual’s informed consent, the fulfilled prescription from a pharmacist, to include:

9.1 patient specific direction 

9.2 saline reconstitution solutions

9.3 storage instructions

9.4 waste disposal protocol

10. select an effective hygiene preparation product to meet the individual’s needs in accordance with the manufacturer instructions

11. prepare the individual’s treatment area in accordance with the botulinum toxin type A procedure protocol and associated risk avoidance strategies, to include:

11.1 mark out pre-procedure markings to identify the hyperhidrotic area of each axilla, according to the hair bearing area

11.2 ensuring markings are sufficiently spaced and evenly distributed

12. prepare the single use syringe, and single use needle in accordance with the procedure protocol

13. inject and deposit the botulinum toxin type A solution subdermally with a sterile, single use needle in accordance with the botulinum toxin type A procedure protocol, to include:

13.1 adaptation of injection techniques, angle and depth 

13.2 in accordance with the pre-procedure markings

13.3 in one smooth motion and slow release to reduce trauma to the area

14. monitor the individual’s health, wellbeing and skin reaction throughout the botulinum toxin type A procedure, in accordance with legislative requirements and organisational policies and procedures

15. in the event of an adverse reaction or incident, the aesthetic practitioner take prompt corrective action, as set out within the emergency plan to include:

15.1 seek and implement immediate medical intervention from the identified healthcare professional trained to deal with complications as set out in the emergency plan when a prescription only medication is required

16. conclude the procedure in accordance with the botulinum toxin type A procedure protocol, legislative requirements and organisational policies and procedures, to include:

16.1 removing any pre-procedure markings, if applicable

17. take and store consensual visual media of the individual’s treatment area in accordance with insurance requirements, organisational policies and procedures 

18. complete the individual's non-surgical cosmetic procedure records and store in accordance with data legislation

19. use reflective practice to evaluate the botulinum toxin type A procedure and take appropriate action

20. provide instructions and advice to the individual, pre and post procedure, to include:

20.1 the regulated independent prescribers contact details 

20.2 emergency plan

20.3 contingency plan in the event of absence

21. discuss, evaluate and record the outcomes with the regulated independent prescriber and agree further action and future procedures

22. discuss the outcomes and agree future procedures with the individual

1. the importance of collaboration with competent professionals to support effective and safe working practices

2. the roles and responsibilities of the independent regulated prescriber 

3. why you must comply with ethical practice and work within the legislative requirements

4. the importance to engage in, and document continuous professional development to include, up-to-date information policies, procedures and best practice guidance 

5. the anatomy and physiology relevant to this standard 

6. the types, composition and pharmacological effects of chemical compounds in botulinum toxin solutions, to include:

6.1 how religion and belief can prohibit a botulinum toxin type A procedure

7. the importance of receiving evidence based diagnosis of primary focal axillary hyperhidrosis or cosmetic excessive sweating from a general medical practitioner, to include:

7.1 the purpose and outcomes of iodine tests

8. the differences between cosmetic excessive sweating, primary and secondary focal axillary hyperhidrosis

9. the reasons for not treating secondary focal axillary hyperhidrosis 

10. how to identify the hyperhidrotic area of each axilla according to the hair bearing area, to include:

10.1 the safe amount of injections to use 

10.2 why you must space injection sites out evenly

10.3 the sterile tools used to mark out the intended injection sites pre procedure

11. the physiological effect of botulinum toxin type A solution has on the underlying tissues of the body, in relation to:

11.1 the inhibited release of acetylcholine neurotransmitter and the effect it has on the parasympathetic nervous system

11.2 why the effect of subdermal injections of botulinum toxin type A is temporary

11.3 the frequency of treatments required in accordance with the individual’s needs

12. the purpose, use and limitations of botulinum toxin type A procedures, in relation to:

12.1 past and current medical history

12.2 previous non-surgical cosmetic procedure history

12.3 relevant lifestyle factors

12.4 medication and medical conditions   

12.5 considering the individual's physical and psychological wellbeing for the botulinum toxin procedure

12.6 individual’s expectations

13. the adverse reactions associated with a botulinum toxin type A procedure 

14. how to implement the correct course of action in the event of an adverse reaction or incident, to include:

14.1 why and when immediate medical invention is necessary

14.2 the risk avoidance strategies 

15. the differentiation between licensed, off label an unlicensed product use, to include:

15.1 the regulatory and legislative requirements

16. the licensed indicated use of prescription only medicines and when and why it can be used off label, considering:

16.1 safety

16.2 treatment area

16.3 suitability 

16.4 agreement with the regulated independent prescriber

17. the types of pain management and associated risks

18. the legislative requirements and restrictions for sourcing, storing and using licensed topical anesthetics

19. the health and safety responsibilities in line with legislation before, during and after the botulinum toxin type A procedure

20. the importance of acquiring and discussing the consultation outcomes with the regulated independent prescriber

21. the importance of obtaining and following instructions from the regulated independent prescriber in line with the medicines management policy, manufacturer instructions, legislative and regulatory requirements, to include:

21.1 access

21.2 use

21.3 storage

21.4 longevity and expiry

21.5 waste disposal policy

21.6 audit and accountability

22. how the regulated independent prescriber’s consultation outcomes inform the botulinum toxin type A procedure plan 

23. why it is important to discuss and establish the individual’s objectives, concerns, expectations, desired outcomes and agree the botulinum toxin type A procedure plan 

24. the importance of using visual aids to inform the individual of the physical effects

25. the fee structures and treatment options

26. why it is important to allow time for the individual to reflect before confirming and agreeing to receive the elective non-surgical cosmetic procedure 

27. the importance of obtaining informed consent for the botulinum toxin type A procedure and pain management 

28. the legislative and indemnity requirements of gaining signed, informed consent for the elective non-surgical cosmetic procedure

29. the types of hygiene products for the skin and the importance of following manufacturer instructions

30. the importance of adhering to the botulinum toxin type A procedure protocol  

31. the importance of monitoring the health and wellbeing of the individual during, and post procedure

32. the importance of adhering to the emergency plan in the event of an adverse reaction 

33. the legislative, insurance and organisational requirements for taking and storing visual media of the individual’s treatment area 

34. the legislative and regulatory requirements of completing and storing the individual’s medical and non-surgical cosmetic procedure records 

35. the expected outcomes from a botulinum toxin type A procedure

36. the importance of discussing, reflecting, evaluating and recording the outcomes with the regulated independent prescriber to inform further action and future procedures  

37. how to collate, analyse, summarise and record evaluation feedback in a clear and concise way

38. the importance to record the outcome and evaluation of the botulinum toxin type A procedure

39. the instructions and advice, pre and post the botulinum toxin type A procedure

Additional information

The regulated independent prescriber is expected to have achieved the relevant qualifications that meet legislative and regulatory requirements. Full qualifications must be on display including pin number and regulatory bodies.

The aesthetic practitioner is expected to already be able to demonstrate competency in determining the relative (restrictive) and absolute (preventative) contraindications for the non-surgical cosmetic procedures. In addition, the aesthetic practitioner should be able to identify adverse reactions or incidents and take prompt corrective action as agreed within the regulated independent prescriber's emergency plan.

Botulinum toxin type A procedure protocol

1. working environment
2. health and safety
3. risk management plan
4. infection prevention and control
5. consultation outcomes from the regulated independent prescriber
6. emergency plan
7. medicine management
8. procedure plan
9. informed consent
10. appropriate professionals
11. data management

12. audit and accountability

13. manufacturer instructions

14. instructions and advice

15. sustainability
16. waste management
17. evidence-based practice
18. reflective practice

Contra-actions

1. hyperemia
2. micro wounds
3. bruising
4. oedema
5. arm pain
6. muscle weakness
7. muscle pain
8. itching in the armpit

Anatomy and physiology

1. the structure and function of all body systems and their interdependence on each other
2. skin and systemic pathologies
3. severe adverse event pathologies
4. basic knowledge of pharmacology and sciences
5. effects of botulinum toxin type A have on the skin and underlying skin structures and muscles 

Competent professionals

Professionals outside your area of competence who you may refer or seek advice.

Adverse reactions

Adverse reactions are also known as adverse incidents or associated risks. An Adverse reaction is an unexpected physical or physiological reaction from a procedure carried out.

Contra-action

Contra action is an expected temporary reaction from a procedure.

Contraindicated

A specific situation in which a drug, procedure, or surgery should not be used because it may be harmful to the person.

Emergency plan

The emergency plan is the responsibility of the regulated independent prescriber. The emergency plan includes the appropriate onsite response, healthcare referral process and access to an emergency kit suitable to deal with adverse reactions or incidents. The regulated independent prescriber has a duty of care to their patients to follow regulatory guidelines set by their Professional, Statutory and Regulated Body.

Patient specific direction 

Prescription specific to the individual and procedure to be carried out.

Pre-procedure markings

Pre-procedure markings should be carried out using a sterile single use surgical pen. Pre-procedure markings are used to create guidelines to identify injection sites as set out in the non-surgical cosmetic procedure plan.

Regulated independent prescriber

Regulated independent prescribers are regulated by Professional Statutory Regulatory Bodies. Regulated independent prescribers will hold the relevant qualifications to receive their registration and pin. Regulated independent prescribers who collaborate with other personnel to carry out botulinum toxin type A procedures are responsible to check the aesthetic practitioner is adequately trained and experienced to administer prescription only medicines.

Visual media

Visual media is evidence generated through photography or video.

​SKANSC11, SKANSC12, SKANSC13, SKANSC1.2, SKANSC2.2