In 2004, the U.S. Food & Drug Administration (FDA) approved BOTOX (onabotulinumtoxinA) for the treatment of severe primary axillary hyperhidrosis (excessive sweating of the underarms) in patients unable to obtain relief using antiperspirants. BOTOX is owned by AbbVie, Inc., and it is the most studied brand of botulinum toxin in the world. BOTOX is approved to treat a total of eight medical conditions in the United States and received its first FDA approval in 1989. Over the years, it has been used to treat millions of patients with various conditions, including spasticity and movement disorders. At least 20 countries have approved BOTOX for the treatment of underarm excessive sweating.
OnabotulinumtoxinA is a natural, purified protein with the ability to temporarily block the secretion of the chemical that is responsible for “turning on” the body’s sweat glands. By blocking, or interrupting, this chemical messenger, botulinum toxin “turns off” sweating at the area where it has been injected. Botox injections are very shallow, meaning that the medicine is injected just below the surface of the skin, where it remains.
Using Botox Injections Effectively
The use of Botox for the treatment of hyperhidrosis can be most effective when performed by a clinician who has received special training from the International Hyperhidrosis Society, and who has experience with the procedure. To find a clinician in your area who is familiar with hyperhidrosis treatments, use our Clinician Finder. Providers who have attended an International Hyperhidrosis Society educational event (which includes intensive, hands-on training on using Botox to treat hyperhidrosis) are designated as having been “IHhS Educated.”
Injections can be administered in a doctor’s office, require relatively little time (very experienced medical professionals can inject both underarms in less than 10 minutes), and do not demand any restrictions in work or leisure activity (aside from refraining from intensive exercise or the use of a sauna on the day of the injections). Prior to Botox injections in the underarms, it’s best not to shave that area. Many healthcare professionals, in fact, prefer three to four days of hair growth prior to Botox injections.
During the procedure, a very fine needle is used to inject tiny amounts of Botox just under the skin intermittently throughout the area of excessive sweating (in a grid pattern, approximately every 1 to 2 centimeters.) Multiple injections are given based on your care provider’s assessment of the area that needs to be treated. To ease any potential discomfort, clinicians may use one or more of a number of anesthetic techniques such as nerve blocks, ice, or vibration analgesia.
After you receive Botox injections for any focal area, it’s recommended that you follow up once with your healthcare provider in 1 to 2 weeks. This follow-up can be useful because it enables your clinician to ‘touch-up’ (see below on “resistance”) any sweating areas that may have been missed during the first round of injections and ensure that you are getting the treatment’s full benefit.
The cost of Botox treatments for hyperhidrosis will vary depending upon the size of the body area you need to be treated and whether insurance will cover any of the cost for you. A general estimate of the cost for two underarms is about $1,000. Botulinum toxin injections do not cure hyperhidrosis; your symptoms will go away gradually (usually in about a week) and return gradually. Follow-up injections are required to maintain dryness. These repeat injections may be necessary at intervals varying from 7 to 16 months.
Botulinum Toxin Resistance?
It is possible for a person to become less responsive, “resistant,” or “immune” to the effects of botulinum toxin injections but it’s rare, often preventable and even rectifiable.
The phenomenon is not yet well understood, but it occurs when the body develops neutralizing antibodies in response to repeated exposure to either the active ingredient in botulinum toxin or supporting proteins in a formula of injectable botulinum toxin.
According to research, approximately 1–3% of those who receive botulinum toxin injections for cosmetic purposes experience results that fade more quickly than before—or even see no effect—despite having good results in the past. There are not many studies on resistance to botulinum toxin among hyperhidrosis patients. The three studies we have seen provide quite different resistance rates from 0.4% to 14% among those receiving botulinum toxin injections for excessive sweating. Some of this disparity may be because of when the studies were conducted; older formulations of botulinum toxin tended to produce higher rates of resistance than newer forms do.
Fortunately, there are steps you can take to help reduce the risk of botulinum toxin resistance.
- Seek botulinurn toxin treatment from an experienced and hyperhidrosis-savvy healthcare provider. A skilled injector knows how to get the best results without excessive product.
- Ensure that your healthcare provider is using a reputable, brand-name botulinum toxin product. In the U.S., there are currently five FDA-approved preparations of botulinum toxin injectables: Botox, Daxxify, Dysport, Myobloc, and Xeomin. Products available in other countries include Azzalure, Nabota, Nuceiva, Vistabel, and Vistabex. New products are also in development.
- Avoid too-frequent botulinum toxin treatments. One dermatologist and plastic surgeon told IHhS that resistance seems more likely to arise in patients who return for “touch ups” weekly. Some experts recommend waiting at least six months between injection sessions. Others say certainly wait at least three months. If you can wait longer, that could be even better. This is a great reminder that hyperhidrosis combination treatments are often more effective than mono-treatments, anyway, and can extend the “life” of your botulinum toxin treatments. Talk to your healthcare provider about how to use antiperspirants, iontophoresis or oral medications, for example, to “boost” your sweat-management results. Also discuss with your healthcare provider any botulinum toxin injections you may be receiving (or are considering) for aesthetic purposes (frown lines, wrinkles, etc.) and weigh the pros and cons of these treatments with the potential risks of resistance.
- Avoid unnecessary “touch-ups.” This relates to #3 above. Yes, it is possible for a sweaty spot to be missed during injections that may require one (not repeated) touch-up visit with your healthcare provider. But, discuss the pros and cons of such touch-ups with your healthcare provider and ensure that you have waited the appropriate amount of time to allow your initial injections to reach their full efficacy (ask your healthcare provider how long you should wait to see expected effects, often 1-2 weeks).
Think you’ve developed resistance to your botulinum toxin injections? All is not lost! Talk to your healthcare provider about using a different botulinum toxin product (see #2 above for options). And/or, take a break from botulinum toxin to allow the “resistance” (neutralizing antibodies) to fade. Some experts recommend a break of six to 18 months. Individual circumstances will vary.
Next Steps
Have you talked to your provider about excessive sweating? If not, now is the time! Learn more about how you and your healthcare team can work together to find the right treatment, or combination of treatments, to manage your hyperhidrosis.
Are you interested in trying local botulinum toxin injections for hyperhidrosis? Our Clinician Finder can help you locate practitioners who treat hyperhidrosis. We also have information and resources to help you prepare for your appointment.
Have an informed discussion with your healthcare team by learning about all of the available treatment options for each of these body areas that may be affected by excessive sweating:
And remember, because hyperhidrosis is a serious medical condition – you deserve insurance coverage and reimbursement for your medical visits and treatment. We’ve got tips to help you navigate the health insurance realm; visit Insurance Tools for more information.
