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[5 min read] Treating hyperhidrosis with Botulinum toxin

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Hyperhidrosis treatments fall into a group of aesthetic medicine procedures which do not directly improve the patients’ physical features. However, they impact their quality of life, social impairment, anxiety, and general stress levels.

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in Aesthetic Medicine.

Doctors in primary care may offer several first and second-line treatments for hyperhidrosis. These usually include topical aluminum chloride (20%) or Botulinum toxin injections.

The latter is in high demand. The reason is the long-lasting effect (6 to 9 months).

What is hyperhidrosis?

The excessive sweating or hyperhidrosis which general practitioners usually encounter in patients is an idiopathic condition. In rare cases, underlying causes are present. These can include:

  • Malignancies,
  • Infections,
  • Neurological or endocrine disorders, or
  • Specific syndromes (LUH, Frey syndrome, Ross Syndrome)

Underlying causes result in secondary hyperhidrosis – a condition that requires medical assistance beyond the primary care level.

Botulinum toxin injections help with idiopathic hyperhidrosis that affects:

  • The armpits (axillary hyperhidrosis),
  • Face/scalp (craniofacial h.),
  • Palms (palmar h.), and
  • Feet (plantar h.).

Diagnosing hyperhidrosis in primary care

Approximately one in two affected patients report excessive sweating. Roughly half of those cases are axillary hyperhidrosis. Most patients seek medical help when they cannot tolerate the condition anymore.

There is nothing physically wrong with people who express hyperhidrosis symptoms. They only produce more sweat.

A general practitioner may diagnose idiopathic hyperhidrosis if the patient reports excessive, visible, and focal sweating for more than six months without a clear cause.

Physical examination and medical history are valuable to rule out an underlying cause.

Additionally, some medications may trigger secondary hyperhidrosis. These include:

  • SSRIs (Prozac)
  • SNRI’s (e.g. Venlafaxine)
  • Pilocarpine
  • Mestinon
  • Insulin
  • Raloxifene
  • Tamoxifen
  • Niacin
  • Sildenafil (Viagra), and more.

To rate the impact of excessive sweating on the patient’s quality of life, doctors can use the Hyperhidrosis Disease Severity Scale or HDSS.

HDSS is a patient survey that helps GPs rate the severity of hyperhidrosis on a scale from 1 to 4 points:

One point – Barely noticeable sweating that does not hamper daily activities.

Two points – Tolerable sweating that may interfere with daily activities.

Three points – Barely tolerable sweating that hampers daily activities.

Four points – Intolerable sweating.

Treatment with Botulinum toxin

The type of Botulinum toxin used for hyperhidrosis treatment is usually onabotulinumtoxinA. A single procedure results in constant improvements in HDSS scores. It reduces local sweat production in the treated area.

Before the procedure, a physician precisely determines the treatment area with a Minor starch-iodine test. Then, Botulinum toxin is injected intradermally. The effects of one treatment may last up to nine months.

How does it work?

Botulinum toxin makes the eccrine sweat glands less active. It blocks the release of acetylcholine from cholinergic neurons by binding synaptic proteins. That obstructs the innervation of eccrine sweat glands, inhibiting their activity.

Who can administer Botulinum toxin injections?

Doctors in primary care can administer Botulinum toxin if they have sufficient training in minimally-invasive injectables and the anatomy of eccrine sweat glands.

Facility requirements

A doctor’s office or a procedure room with standard equipment for aesthetic medicine procedures will suffice for hyperhidrosis treatment with Botulinum toxin injections.

– Dr Rosmy De Barros

Read another article like this one: How can a GP get started providing cosmetic services in primary care?


  1. Melissa A. Doft, Krista L. Hardy, Jeffrey A. Ascherman, Treatment of Hyperhidrosis With Botulinum Toxin, Aesthetic Surgery Journal, Volume 32, Issue 2, February 2012, Pages 238–244, https://doi.org/10.1177/1090820X11434506
  2. Beyer C, Cappetta K, Johnson JA, Bloch MH. Meta-analysis: Risk of hyperhidrosis with second-generation antidepressants. Depress Anxiety. 2017;34(12):1134-1146. doi:10.1002/da.22680
  3. Nigam PK, Nigam A. Botulinum toxin. Indian J Dermatol. 2010;55(1):8-14. doi: 10.4103/0019-5154.60343. PMID: 20418969; PMCID: PMC2856357.
  4. VALIDITY AND RELIABILITY OF THE HYPERHIDROSIS DISEASE SEVERITY SCALE (HDSS) Jonathan W Kowalski, PhmD, Allergan, Inc., Irvine, CA, United States, Nina Eadie, BS, Allergan, Inc., Irvine, CA, United States, Simon Dagget, BS, Allergan, Inc., Irvine, CA, United States, Pan-Yu Lai, PhD, Allergan, Inc., Irvine, CA, United States

3 comments on “[5 min read] Treating hyperhidrosis with Botulinum toxin

    1. Hi Sally, here is a response from the author of the article:
      It rarely happens that Botulinum toxin does not work. I would always recommend trying again after six to nine months. If that does not work, there are some more expensive and more invasive options available, such as microwave therapy or suction curettage (sweat glands removal).

      Thank you.
      – Abbie | HealthCert Education

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