Hyperhidrosis has a significant impact on a person’s physical, psychological, and social aspects of life. The lack of treatment options and associated stigma limits access to care and treatment options.
Primary hyperhidrosis does not have an underlying cause; is symmetrical; can worsen with anxiety, fear, or stress; and may have a familial component. Palmar and axillary hyperhidrosis are the most common types of hyperhidrosis. The incidence of craniofacial hyperhidrosis has not been clearly defined but it is most commonly reported on the forehead, where the concentration of eccrine sweat glands is highest.
Dr. Lily Talakoub
Treatment options for craniofacial hyperhidrosis include topical aluminum chloride, which blocks the eccrine sweat duct or causes eccrine cell atrophy. Although this option is a common treatment for palmar and axillary hyperhidrosis, use on the face has not been thoroughly studied, and may also cause skin irritation.
Topical and oral glycopyrrolate can be effective for all types of hyperhidrosis, but must be used daily and can have systemic side effects, with variable efficacy and longevity. Oral oxybutynin, beta-blockers, clonidine, and benzodiazepines have also been used with some limited studies available in patients with generalized hyperhidrosis.
Surgical treatments such as videothoracoscopy sympathectomy can be used in severe or recalcitrant cases of hyperhidrosis with good efficacy. However, surgical complications and inherent surgical risks limit these treatment options unless other modalities are exhausted.
OnabotulinumtoxinA is Food and Drug Administration approved for treating severe primary axillary hyperhidrosis, but is used off label for palmar, plantar, and craniofacial hyperhidrosis with great results and few side effects. Clinical pearls and guidelines for the use of botulinum toxin A in craniofacial hyperhidrosis were outlined by Wolosker and colleagues in a review article. As with any injection of neurotoxin, knowledge of the facial anatomy is critical to avoiding muscle paralysis.
double diluted. Treatment effects usually last 3 months, similar to cosmetic uses. Wolosker uses a dilution of 100 U botulinum toxin in 1.0 mL saline, which I find slightly more difficult to control and more likely to have loss of toxin.
In my experience, I have found the following dosing to be most effective with the least side effects for the following (dosages vary and can be titrated up to response):
- Upper lip: 6-10 U.
- Chin: 6-10 U.
- Forehead: 15-30 U. (Avoid 1 cm above the brow unless risks of brow drop are reviewed and acceptable to the patient. In my experience patients would rather have a lower brow than obstructive sweating in their brow that can irritate the eyes, blur vision, and smudge skincare and makeup.)
- Nose: 10 U
- Cheeks: 10 U per side (staying very superficial with injections).
- Scalp: 30-50 U (using serial injections 1-2 cm apart in the area affected by hyperhidrosis).
Side effects include temporary erythema, bruising, and edema, as well as muscle paralysis and asymmetry if proper injection technique is not used, the dose is not diluted properly, or the injection is too deep.
There are scattered case studies of symbiotic techniques to help the penetration of botulinum toxin when treating craniofacial hyperhidrosis, including microneedling, radiofrequency, long-pulsed diode laser, and ultrasound. But the safety and efficacy of these procedures have not been properly evaluated.
In all of my patients with craniofacial hyperhidrosis treated with botulinum toxin, quality of life is significantly improved with almost no complications. Botulinum toxin is a safe, relatively quick in-office procedure to treat craniofacial hyperhidrosis that can be used to help patients – particularly those who experience anxiety or have social and occupational impairment related to their disease.
This procedure is cosmetic in nature, and therefore, not covered by insurance.
Dr. Talakoub is in private practice in McLean, Va. Write to her at dermnews@mdedge.com. She had no relevant disclosures.
References
Parashar K et al. Am J Clin Dermatol. 2023 Mar;24(2):187-98.
Doolittle J et al. Arch Dermatol Res. 2016 Dec;308(10):743-9.
Wolosker N et al. J Vasc Bras. 2020 Nov 16;19:e20190152.
Garcia-Souto F et al. Dermatol Ther. 2021 Jan;34(1):e14658.
Ebrahim H et al. J Clin Aesthet Dermatol. 2022 Sep;15(9):40-4.
Campanati A et al. Toxins (Basel). 2022 May 27;14(6):3727.