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Hyperhidrosis — Botulinum Toxin Therapy

Onabotulinumtoxin A (Botox) intradermal injection for primary focal hyperhidrosis (axillary, palmar, plantar, craniofacial), targeting cholinergic sweat-gland innervation with 4–9 month efficacy and high patient satisfaction (HDSS reduction).

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Dermatoloji department. Book Appointment →

What is Hyperhidrosis — Botulinum Toxin Therapy?

Botulinum toxin A (BoNT-A) is a presynaptic SNAP-25 cleaving neurotoxin produced by Clostridium botulinum that blocks acetylcholine release at neuromuscular and cholinergic-autonomic junctions. In hyperhidrosis treatment it inhibits the cholinergic stimulation of eccrine sweat glands by sympathetic postganglionic fibers, producing local anhidrosis without affecting sensation or motor function (when proper depth and dose used).

Indications include primary focal hyperhidrosis—axillary (FDA-approved 50 U/axilla), palmar (off-label 75–150 U/palm), plantar (off-label 100 U/sole), craniofacial (30–50 U/region), inguinal/inframammary, gustatory (Frey syndrome) and stump hyperhidrosis—after failure of conservative measures (20% aluminum chloride hexahydrate, glycopyrrolate 0.5–1% topical, oral anticholinergics).

Technique involves Minor iodine-starch test for sweat mapping, intradermal injections in 1.5–2 cm grid pattern, 30G needle, 1–2 U per site (axilla 50 U total, palm 100 U total, sole 100 U total). Anesthesia is unnecessary for axilla, but ulnar/median nerve block, vibration analgesia, ice or topical EMLA for palms/soles. Onset in 2–7 days, peak at 2 weeks, duration 4–9 months. Side effects include transient hand weakness (palmar), headache, injection-site pain.

Symptoms

Visible sweat-stained clothing, dripping sweat at rest in target area
Cold, wet, clammy palms or soles affecting grip, walking, social interactions
HDSS (Hyperhidrosis Disease Severity Scale) score 3 or 4
Compensatory sweating in non-target areas
Skin maceration, fungal infection, contact dermatitis from chronic moisture
Anxiety, social withdrawal, occupational impairment
Failed antiperspirants, iontophoresis, oral anticholinergics

Risk Factors

Bleeding diathesis or anticoagulant use (relative contraindication)
Active skin infection at injection site
Neuromuscular disease (myasthenia gravis, Lambert-Eaton, ALS)
Pregnancy or lactation (limited data, generally avoided)
Aminoglycoside or other neuromuscular-blocking medications
Known allergy to botulinum toxin or albumin
Previous failed BoNT-A response (immunoresistance, neutralizing antibodies)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent excessive sweating despite > 4 weeks of high-strength antiperspirants
  • Sweating that interferes with daily activities, relationships, or work
  • Skin breakdown, secondary infection from chronic moisture
  • Failure of topical glycopyrrolate or oxybutynin
  • Side effects intolerable from oral anticholinergics
  • Considering alternative to surgery (endoscopic thoracic sympathectomy)
  • Worsening symptoms in adolescence or young adulthood

Treatment Methods

01
Pre-procedure: Minor iodine-starch test mapping, photo documentation, HDSS scoring, baseline gravimetric sweat measurement if available
02
Anesthesia: none for axilla; topical EMLA, vibration, ice, or peripheral nerve block (ulnar, median) for palmar; ankle block for plantar
03
Reconstitution: 100 U vial with 4 mL preservative-free saline (2.5 U / 0.1 mL); 30G needle, 1 mL syringe
04
Axillary technique: 1.5–2 cm grid, 1–2 U per injection, total 50 U/axilla, intradermal at 45° angle
05
Palmar/plantar: 1.5 cm grid, 2 U per site, total 100 U/palm or sole; warn about transient hand weakness 2–4 weeks
06
Craniofacial: 30–50 U total, superficial intradermal to avoid frontalis/zygomatic muscle weakness
07
Repeat dosing every 4–9 months as efficacy wanes; combine with iontophoresis, microwave thermolysis (miraDry), or surgical sympathectomy in refractory cases

Which Department to Visit?

You can visit our Dermatoloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Let us help you

You can make an appointment with our specialists or contact us for your concerns.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.