Hyperhidrosis with Botox

Chronic sweating, excessive sweating can substantially affect an individual's emotional well-being, and their social life. Therapies available, before neuromodulators were available, were generally topical, with limited effectiveness, time-consuming, and often caused subsequent skin reactions. Injections of neuromodulators, such as Botox, to treat sweat glands have more recently arose, just in the past few decades, as a novel therapeutic approach.

Studies have shown that treating the axillary area with Botox significantly reduces sweat production and axillary hyperhidrosis severity (Lowe et al., 2023). These effects are rapid, within a week of administration, and they last at least six months. Studies have found that these injections are associated with significant improvement in quality of life, both physically and mentally. Studies have also shown that this treatment is well tolerated.

What is Hydrohidrosis?

Sweating is a normal part of human thermoregulation; however, when it happens in excess, uncontrollably, as occurs when one has hyperhidrosis, it can lead to substantial emotional and physical impairments in a person's occupation and social life (Lessa et al., 2014). In fact, hyperhidrosis is as impactful, negatively, on one's life as severe acne and psoriasis (Naumann et al., 2002).

Ninety percent of these cases are idiopathic, meaning there is no identifiable pathologic cause (Walling, 2011). About ten percent though, are related to a primary endocrine or neurologic disease, or even the side effect of a medication, infection, malignancy or metabolic or endocrine or cardiovascular disease. Primary hyperhidrosis, with no identifiable cause, typically presents before the age of 25 years, in both palms, soles of the feet, both axillary areas, and/or even around the forehead. This tends to cease during sleep. In contrast, secondary hyperhidrosis typically occurs at a later age, and is more likely to occur in just one hand or one axillary area, and more generalized. This secondary type also tends to be present during sleep.

When cases are more severe, individuals may have physical complications, such as break down of the skin and infections (Heckmann et al., 2001). Despite this burden, only about half of those with this condition even talk to their clinician about their condition (Doolittle et al., 2016).

Why Does This Happen?

Although we don't quite understand why hyperhidrosis occurs, it is believed to be related to malfunctioning in the autonomic nervous system, leading to hyperstimulation of otherwise normal eccrine sweat glands (Lowe et al., 2023). These sweat glands are innervated by sympathetic cholinergic nerve fibers, and the stimulation of these fibers leads to sweating. This is worse, of course, where there are more sweat glands and the palms and soles are activated mostly by emotional stimuli which is why this doesn't occur during sleep.

There does seem to be a genetic association to primary hyperhidrosis, with 6% to 65% of those with a positive family history demonstrating an autosomal dominant mode of inheritance with incomplete, and variable, penetrance. The abnormality has been linked to chromosome 14q (Del Sorbo et al., 2011). Stress, anxiety, and fear trigger our sympathetic cholinergic nerves, or the dysregulation of the areas of the body that respond to emotion with sweating. Nevertheless, the link between emotions and hyperhidrosis via the autonomic mechanism may be incomplete.

Hyperhidrosis is Distressing and Debilitating

Even if we don't understand the why, we do know that hyperhidrosis is incredibly life altering, distressing, and debilitating. Individuals have shared that engaging in basic, everyday social interactions are compromised (Lowe et al., 2023). Clothing is expensive to replace when stained because of sweat, and most treatments don't offer long-term treatment. In a 2004 survey, approximately one-third of those with axillary hyperhidrosis reported that sweating was intolerable or barely tolerable, and frequently or always interfered with daily activities (Strutton et al., 2004).

Among those who seek care for axillary hyperhidrosis, quality of life deficits are comparable to those experienced by people who receive inpatient care for eczema and psoriasis (Tan & Solish, 2002). One study found that more than 70% of people with hyperhidrosis change their clothing more than twice a day (Naumann et al., 2002). This percentage decreased significantly with onabotulinumtoxinA, remaining below 10%.

There is a marked compromise in quality of life for those with hyperhidrosis...it's not only a cosmetic problem...it's a disease that compromises quality of life. The way that Botox injections can improve quality of life makes it extremely convincing that this is the treatment of choice.

How is One Diagnosed?

Your primary care provider can offer diagnosis if excessive sweating lasts greater than six months, without any obvious cause and at least two of the following features: impairing daily activities, occurring on both sides of the body and relatively symmetric at least once a week, with onset younger than 25 years of age, ceasing during sleep, or a positive family history (Hornberger et al., 2004).

What Treatments are Available?

Treatment options for hyperhidrosis include topical application of aluminum chloride, systemic anticholinergic agents, B-blockers, and iontophoresis (Nawrocki & Cha, 2019). Anticholinergic agents (glycopyrrolate, menthatheline bromide, oxybutynin) and alpha-adrenergic agonists (clonidine) are most commonly used in clinical practice. These aren't all tolerated well though, nor are they entirely effective, and they are often incredibly inconvenient. Dry mouth, blurring vision, urinary hesitancy, dizziness, elevated heart rate, and confusion can be pretty debilitating in themself (Walling & Swick, 2011). However, these are the first-line approach, particularly for teenagers who aren't often inclined to do injections.

The use of microwave-based energy devices to physically ablate axillary sweat glands has been evaluated for treating hyperhidrosis (Lin et al., 2021). These studies have shown significant, long-term effects in reducing sweat severity, but there are adverse outcomes related to the procedure, including pain and swelling. These do seem to be mild though, and resolve in 2 to 3 weeks. More long term effects included altered sensation in about 10%, sometimes as high as 40%, and nodule formation in about 3 to 25%. The altered sensation does resolve, on average, in 7 to 10 weeks and nodules resolve in about 4 weeks.

When these treatments fail, we have historically offered surgical removal of sweat glands or part of the sympathetic nerve trunk of the thoracic region. Sympathectomy can be associated with high rates of recurrence, in upwards of 65%, and compensatory sweating, in 98%, and a risk of serious complications generally associated with the site of surgery, such as Horner syndrome, neuralgia, and pneumothorax (Nawrocki & Cha, 2019). Surgery is typically limited to those impacted under the age of 25 years of age, those with low body mass index, and no nocturnal sweating or low heart rates, as this limits pharmaceutical treatment.

Use of Botox for Hyperhidrosis

The use of onabotulinumtoxinA for hyperhidrosis was really a very logical extension of its mechanism of action, as it inhibits the release of acetylcholine from overactive cholinergic sympathetic neurons. As early as 1951, botulinum toxin type A was shown to reduce or eliminate sweating from sudomotor nerve stimulation in preclinical experiments, thus providing rationale for onabotulinumtoxinA as a treatment for hyperhidrosis (Naumann & Lowe, 2001).

Delivery of onabotulinumtoxinA for this disease requires intradermal injection near the cholinergic sweat gland, rather than the skeletal muscle, and doses are lower and last longer for this indication as opposed to relaxing muscles (Lowe et al., 2023). This requires training to administer and knowledge about placement and depth of sweat glands. These have been performed in the axillary (armpits), palmar (palms), and plantar (soles of feet) since 1928 and used in clinical studies beginning in the 1940s and 1950s. In early anecdotal reports, sweating was reduced within 48 hours of onabotulinumtoxinA injection, and most initial people with axillary hyperhidrosis achieved sweating control for 12 to 28 weeks after a single procedures (Naumann & Lowe, 2001).

Studies have demonstrated that onabotulinumtoxinA treatment for hyperhidrosis is well tolerated, with neither study demonstrating significant differences between onabotulinumtoxinA and placebo groups. Only 5% continue to have sweating after receiving the neuromodulator in one study, and 6-10% in another study, less so when the dose is higher. Pain occurred at the site for about 2 days, at most 10 days, and few experienced some bleeding (Naumann & Lowe, 2001 & Lowe et al., 2007). The European Medicines Agency approved the use of onabotulinumtoxinA for persistent severe primary axillary hyperhidrosis in 2003. The US Food and Drug Administration approved it for the treatment of primary axillary hyperhidrosis in 2004 (de Almedia & Montagner, 2014).

Today, four types of neurotoxins are approved, including Botox, Xeomin, Dysport, and Myobloc. These are administered in a grid like pattern throughout the treated area, and because they are injected, this can be a bit uncomfortable. Emla cream, an hour prior to injection, can be helpful, or even an anesthetic spray. A vibrating beauty bar can also utilize the Gate Theory for minimizing pain. There is also a botox mixture with lidocaine called A/Ona that has shown effective (Lakraj et al., 2013).

One of the more interesting findings regarding the use of onabotulinumtoxinA for hyperhidrosis is that when we use it for this purpose, to halt the excretion of sweat, it lasts significantly longer than when we inject it into muscle. Typically when utilizing for aesthetics purposes, these injections last about 3 to 4 months, but we often see results last 6 to 7 months for this intention. At least 22% of people continue to have therapeutic benefits for up to a year after their first treatment (Lowe et al., 2007).

Certainly, if you are considering this option, I am happy to assist. Injections of neuromodulars to minimize sweating is a skillset I am happy to offer, whether in the office or privately in the comfort of your home.

Need for Greater Awareness

Excessive sweating is not commonly something individual's seek treatment for, maybe because of embarrassment or shame, or maybe because of cost. What we find though is that more often, it's because they don't recognize this as a medical issue, with an effective solution. Since botox treatments were first offered, the rates of diagnosis have increased exponentially, largely because as treatment has shown effective, disease awareness has grown and more have sought treatment. Even in the medical community, hyperhidrosis has evolved from a subjective condition to a disease. Until just more recently, the medical community has really thought of this disorder as an emotional malady more so than a disease (Lima & de Santana, 2018).

Sometimes hyperhidrosis occurs as a side effect of medications, such as sertraline, or after exposure to a toxin, such as acrylamide. It may be related to a systemic illness, as mentioned above. Syndromes may even associated. It is thought that one in two-hundred, or even one in a hundred, suffer from debilitating effects of hyperhidrosis (Lakraj et al., 2013).

References

de Almeida, A. R. T. & Montagner, S. (2014). Botulinum toxin for axillary hyperhidrosis. Dermatol Clin, 32, 495-504.

Del Sorbo, F., Brancati, F., de Joanna, G., Valente, E. M., Lauria, G., & Albanese, A. (2011). Primary focal hyperhidrosis in a new family not linked to known loci. Dermatology, 223, 335-342.

Doolittle, J., Walker, P., & Mills, T. (2016). Hyperhidrosis: an update on prevalence and severity in the United States. Arch Dermatol Res, 308, 743-749.

Heckmann, M., Ceballos-Baumann, A. O., & Plewig, G. (2001). Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med, 344, 488-493.

Hornberger, J., Grimes, K., Naumann, M., Glaser, D. A., Lowe, N. J., Naver, H., Ahn, S., & Stolman, L. P. (2004). Recognition, diagnosis, and treatment of primary focal hyperhidrosis. Journal of American Academia and Dermatology, 51, 274-286.

Lakraj, A-A., Moghimi, N., & Jabbari, B. (2013). Hyperhidrosis: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins, 5(4), 821-840.

Lessa Lda, R., Luz, F. B., & De Rezende, R. M. (2014). The psychiatric facet of hyperhidrosis: demographics, disability, quality of life, and associated psychopathology. J Psychiatr Practice, 20, 316-323.

Lima, S. O. & de Santana, V. R. (2018). The prevalence of hyperhidrosis worldwide. In: de Paula Loureiro M., de Campos, J. R. M., Wolosker, N., Kauffman, P. (Eds.). Hyperhidrosis: a complete guide to diagnosis and management. Cham: Springer International Publishing, 33-38.

Lin, M. J., Dubin, D. P., & Genece, J. (2021). A survey of long-term results with microwave energy device for treating axillary hyperhidrosis. J Cosmet Laser Ther, 23, 49-51.

Lowe, N., Naumann, M., & Eadie, N. (2023). Treatment of hyperhidrosis with Botox (onabotulinumtoxinA): development, insights, and impact. Medicine, 102.

Naumann, M. K., Hamm, H., & Lowe, N. J. (2002). Effect of botulinum toxin type A on quality of life measures in patients with excessive axillary sweating: a randomized controlled trial. British Journal of Dermatology, 147, 1218-1226.

Nawrocki, S. & Cha, J. (2019). The etiology, diagnosis and management of hyperhidrosis: a comprehensive review. Part II. Therapeutic options. J Am Acad Dermatol, 81, 669-680.

Strutton, D. R., Kowalski, J. W., & Glaser, D. A. (2004). US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol, 51, 241-248.

Tan, S. R. & Solish, N. (2002). Long-term efficacy and quality of life in the treatment of focal hyperhidrosis with botulinum toxin A. Dermatol Surg, 28, 495-499.

Walling, H. W. (2011). Clinical differentiation of primary from secondary hyperhidrosis. J Am Acad Dermatol, 64, 690-695.

Walling, H. W. & Swick, B. L. (2011). Treatment options for hyperhidrosis. American Journal Clinical Dermatology, 12, 285-295.