Botox for Sweating FAQs

The effect of it on our lives can vary from embarrassing to truly devastating.  All too often, living with hyperhidrosis becomes a silent struggle: avoiding social contacts, trying to disguise the excessive sweating with clothing, powders, and pads. Our social, professional, and even most intimate relationships may be seriously affected.
Even though hyperhidrosis is a medical condition that can have profound and devastating effects on our physical and mental well-being, most insurance companies will not reimburse plan members for the treatment.
 
Most patients with excessive sweating report noticeable physical discomfort with having wet clothing and shoes. Skin maceration from constant wetness can lead to bacterial and fungal overgrowth. This overgrowth can then result in irritation in the armpits as well as foul body smell.  Excessive sweat stains and eventually destroys clothing and shoes. Some patients may spend thousands of dollars every year on dry-cleaning and buying new clothes.

Reportedly, one college professor with armpit sweating was embarrassed to find out that his students made daily bets on whether his sweat stains would reach his belt by the end of the day.

Not surprisingly, in a U.S. national consumer survey, over ½ of patients with armpit sweating reported feeling less confident, over 1/3 are frustrated by some daily activities, and feel unhappy, and 1/5 are depressed. Our social, professional, and even most intimate relationships may be seriously affected.
 
The patients with hand sweating constantly wipe on clothing or towels, and try to avoid handshaking. Over 90% of patients with palm sweating reported social embarrassment, and 40% had some psychological difficulties due to their symptoms. Having sweaty palms makes it difficult to grip tools, play musical instruments, and use electronic devices, paper can be stained and ink smeared by dripping sweat.

Since primary hyperhidrosis begins in childhood, adolescence, or young adulthood, career choices of the patients also may be affected. Positions like education or sales and marketing that require frequent handshaking or presentations may be very difficult.

Based on our clinical experience in treating patients with excessive sweating, as well as from formal studies, hyperhidrosis is a condition that has a profound negative impact on patients’ lives. Patients with excessive sweating need to be offered appropriate and customized treatment in order to lessen the physical, psychosocial, and occupational impact of their condition.

For most people, there may be no explainable cause for their excessive sweating.  In these patients it is considered essential or idiopathic or primary hyperhidrosis. This may be happen to excessive activity of the nerves that send signals to the sweat glands in the skin.

Sometimes this idiopathic form of hyperhidrosis can be genetically transmitted, and it often runs in families; this form may first show up in early childhood. Other patients may have sweating as a symptom of other medical conditions, such as
          an overactive thyroid gland (hyperthyroidism),
          nerve damage due to diabetes or spinal cord injuries,
          psychiatric disorders such as panic attacks or anxiety disorders,
          hot flashes associated with menopause.
          Some medications may also cause excessive sweating, such as
                   the medications often used for prostate cancer,
                  AIDS, or
                  myasthenia gravis.

Sweat glands are located in the deep layer of the skin, and make sweat by filtering fluids and salts out of the blood, and expressing it through small openings on the surface of the skin. There is two to four million sweat glands spread all over our skin surface. Some areas of the body have many sweat glands, while others have relatively few.
 
Sweating is a normal bodily function that serves to cool off and lubricate the skin in areas that may rub against other areas of skin, such as under the arms, under the breasts, and between the legs.

In addition to sweat glands, there are sebaceous glands in the skin.  They surround hair roots, and produce body oils. 
Certain areas, such as the armpits and the groin, have a special type of sweat gland called apocrine glands.  These glands produce a very thick sweat with large amounts of fatty substances in it. These substances are broken down by bacteria on the surface of the skin and create the smelly body odor. When these glands are infected, it may lead to a condition known as hidradenitis suppurativa, a serious medical condition that requires antibiotics or surgery for cure.

Sweating is regulated by our nervous system.  There are 2 parts of the nervous system.  The sympathetic nerves tend to increase sweating.  The parasympathetic nerves tend to decrease it. Our nerve endings release special chemicals called acetylcholine.  Most doctors feel that in people with idiopathic sweating (hyperhidrosis) the sympathetic nerves are over stimulated, making too much acetylcholine.

There are 4 ways to decrease sweating:
          Cut down the nerve impulses to the sweat glands,
          cut down on the acetylcholine,
          destroy the glands,
          block off the skin openings.
The most commonly used method is to plug up the ducts.  This is how antiperspirants work.

Excessive sweating of hands (palmar) may be the most distressing problem. This is the most common form of excessive sweating. Many patients who suffer from hand sweating start having the symptoms at a young age. We use our hands socially and professionally more than any other part of the body. Excessively wet or moist hands may severely limit our social interactions or even a choice of profession.

For palmar sweating a low grade of involvement would be a moist palmar surface without visible droplets of perspiration. If sweating extends toward the fingertips, the condition can be considered moderate.  If sweat drips off the palm and reaches all the fingertips, it is severe.

This condition it can be aggravated by emotional stimuli.  There are a few treatment options that had been tried.  They range from lotions, pills and herbal medications to bio feedback, electric currents application (iontophoresis), acupuncture, and surgery.  In our experience the most reliable treatment with minimal overall complications is Botox.  However, we encourage you to read about all available options.

Excessive sweating of armpits (axillary) causes large wet stains on the clothes. In addition to embarrassing look, strong body odor may also develop. Both can cause very negative emotional and psychological impacts. 

For armpit sweating, the severity of the condition can be determined by the size of the sweat stain on the shirts and blouses. A sweat stain with a diameter less than 5 cm is considered normal. Mild axillary hyperhidrosis is associated with stains 5 to 10 cm in diameter and still confined to the armpit.  Stains of 10 to 20 cm are indicative of moderate hyperhidrosis.  The stains over 20 cm, especially reaching the waistline are considered in severe hyperhidrosis.
It can be associated with hand sweating (palmar hyperhidrosis) in about 40% of the patients or it can be presented on its own.

The armpit area has two types of sweat glands, eccrine and apocrine glands. The eccrine glands will be affected by sympathectomy.  This is not so for the apocrine glands.

For those patients who have the armpit sweating together with the hand sweating sympathectomy will help in about 75 to 80% of the cases. For those who suffer from only armpit sweating it does not help as much.   Our recommended options of treatment include superficial Liposuction or Botox injections.

Antiperspirants are usually the first treatment recommended.  Most people will initially try simple measures to control their excessive sweating. Dusting powders, like cornstarch and talcum powder, may help for a short while.  The sweating, however, can often be so profuse, that it washes the powder away.

Many people have tried regular spray or roll-on antiperspirants, astringent solutions such as aluminum acetate or aluminum sulfate to soak their feet or hands. Others tried stronger aluminum containing prescription preparations, such as 6% aluminum chloride (Xerac™ AC), or 20% Drysol™.  These aluminum compounds cause the sweat in the ducts to solidify, plugging up the sweat pores.  Unfortunately, they may become less effective over time.  They may also cause skin irritation, rashes and stinging sensations.

Iontophoresis is usually tried, when antiperspirants are not effective.  It is used to treat palmar, axillary, and plantar sweating.  A low intensity electrical current is applied to the palms and soles immersed in a special electrolyte solution.  It has to be repeated regularly.  Initially the 20 minute sessions are done several times per week then gradually the interval between treatments is increased to every 1 to 2 weeks.

Unfortunately, the results vary.  Some patients suffering from light to moderate sweating (hyperhidrosis) of hands and feet are happy with the method.   Others may consider it too time-consuming, inefficient and relatively expensive. Also it is very difficult to apply in armpits and groin and impossible to use in diffuse hyperhidrosis of the face or the trunk.  Side effects may include burning, electric shock, and discomfort, tingling and skin irritation.   Sweating usually returns after the treatment is stopped.

There is no specific medication to treat hyperhidrosis. Several medications can be used to help with excessive sweating.  For people who suffer from hyperhidrosis throughout their entire body, the ability to control excessive sweating by taking a simple tablet can be the most convenient.  For those of us suffering from localized sweating (hands, armpits, groins or feet) localized treatment is a better solution.

The patients who suffer from sweating as a symptom of an anxiety, panic or social anxiety disorder, usually get unreasonably nervous in certain situations. They are treated with specific psychiatric medications, or with psychotherapy.
For people who suffer from diffuse trunk sweating, or facial blushing, medications that block acetylcholine are used.  Glycopyrrolate (Robinul®),  ProBanthine® and oxybutynin Ditropan® are most commonly used medications. 

However, these medications produce only temporary effect and block acetylcholine at other sites through out the body causing such side effects as dry mouth, blurred vision, urinary problems, constipation, rapid heartbeat and many others.

None of these drugs are formally FDA approved for use in hyperhidrosis. 

Other medications, such as beta blocker propranolol (Inderal®) is also used.  This medication may help with tremor, cracking voice, rapid heartbeat, and even the sweating that public appearances may produce in some people.  However, it must be used very carefully, especially by people with asthma, diabetes, lung or heart diseases due to significant systemic effects.

Topical gels, lotions and creams containing these medications can be compounded by many pharmacists, and may be applied onto the skin at particularly bothersome sites.  Some physicians even use iontophoresis to drive these medications into the skin.

There are several surgical options available for the treatment of excessive sweating. 

Superficial liposuction is used for underarm sweating.  Using a small special cannula the sweat glands are removed.  The procedure takes about an hour and is done in office operating room under local anesthesia with light sedation.  The patient usually goes home within a couple of hours.  The success rate is about 95%.  Recovery takes about 1-3 weeks.

Axillary Sweat Gland Removal   This surgery involves removing sweat glands from the armpits by surgically excising them.  It tales a couple of hours and is done under general anesthesia or local with sedation.  The scar is quite large.  Usually a Z-plasty needs to be done to prevent scar contracture.  Unfortunately, the scar can become hypertrophic and restrict shoulder motion.

Endoscopic Thoracic Sympathicotomy   The main surgical treatment for excessive sweating is endoscopic thoracic sympathicotomy (or sympathectomy).  It is performed in an operating room under general anesthesia.  This is a surgical procedure where a lighted scope is inserted through the armpit on both sides into the chest cavity over the lung, and the sympathetic nerves to the face and upper arms are cut, crushed or destroyed. 

This procedure, known as ETS, will not usually help people with hyperhidrosis of the underarms, feet, or body, but may be very helpful for hands or face.   Some patients report that after surgical sympathectomy a regular deodorant is enough to control their armpit sweating whereas before the operation it did not help.

The patient usually go home the same day, and can expect a full recovery in about 1 week. The improvement of sweating is immediate.  However, here are complications of this surgery that include pneumothorax is a life threatening condition when excessive air is collected in the chest cavity outside of the lungs.  Chest tube may need to be placed to save life.)
Horner's syndrome (about 1% of cases), bleeding, infection and injury to the surrounding tissues.

There is another problem with this surgery.   Many patients may develop compensatory sweating elsewhere, which may be troublesome.   Also this surgical procedure is permanent, so that if one is suffering from compensatory sweating after the surgery, there is no other treatment other than medication or antiperspirants to control it. Many insurance companies will not cover this procedure which can cost between $5,000 and $10,000.

If you are considering ETS, you should obtain multiple medical opinions on all the options available to you prior to the surgery.  Make sure you consult with the doctor who provides Botox treatments and who DOES NOT perform this procedure.

Over the last 3 years, we have recognized that BOTOX® can dramatically reduce excessive sweating.  Dr. Volshteyn had treated over a dozen patients with excessive armpit sweating with excellent results. 

Now BOTOX® is indicated and FDA approved for the treatment of severe primary axillary hyperhidrosis (severe underarm sweating) that is inadequately managed with topical agents.  BOTOX® treatment is very effective. In one clinical study, 81% of patients achieved a greater than 50% reduction in sweating.  BOTOX® treatment helps control this condition by temporarily blocking the chemical signals from the nerves that stimulate the sweat glands. In our experience relieves most cases of localized hyperhidrosis (excess sweating). Botox offers the patients with this condition a significant alternative to surgery

Botox® is also the answer for people who feel they are sweating too much.  Botox® treatment can be performed a week or so before a high stress event such as a job interview, business meeting, wedding or public speaking engagement.
The injections are performed in privacy of our office, require no anesthesia, and absence of sweating is long lasting..  Dr. Volshteyn  uses advanced techniques to maximize his patients comfort making the injections almost painless. Patients who have had Botox® injections by other physicians have frequently commented on how much more comfortable Dr. Volshteyn approach is. 

The amount of Botox used is similar for wrinkles and frown lines. Most patients report decrease of underarm sweating within 48 hours of the treatment. They remain dry in the underarms for periods ranging from 4 months to 9 months, or even 12 month.  But BOTOX® is not a cure; the symptoms will return gradually, and you will know when the time is right for another treatment. In most cases the treatment needs to be repeated at least once a year.  People usually request re-injections 6 - 12 months later, even though only some of the sweating has returned. We will recommend you a treatment strategy to ensure that you receive the best possible results with BOTOX.  

BOTOX® treatment is contraindicated if there is an infection at the injection site or in individuals with known hypersensitivity. Patients with neuromuscular disorders (e.g., myasthenia gravis or Lambert-Eaton syndrome) should only receive BOTOX® treatment with great caution.

The most frequently reported side effects (3% to 10% of patients) following BOTOX® injection were mild pain and minimal bleeding, sweating, infection, inflammation, flu syndrome, headache, fever, neck or back pain, itching, and anxiety.

Even though hyperhidrosis is a medical condition that can have profound and devastating effects on our physical and mental well-being, most insurance companies will not reimburse plan members for the treatment.  The cost varies from $900 to $1500 for both sides.