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Botulinum toxin A for primary axillary hyperhidrosis: a narrative review

J Med Life. 2026 Jun;19(6):420-425. doi: 10.25122/jml-2026-0005.

ABSTRACT

Primary axillary hyperhidrosis (PAH) markedly impairs psychosocial well-being and daily functioning. Botulinum toxin type A (BoNT-A) is widely used, both on- and off-label, to suppress eccrine sweating through presynaptic inhibition of acetylcholine release and temporary chemodenervation of cholinergic sympathetic fibers. This narrative review synthesizes published clinical evidence between 2000 and January 2025 regarding the efficacy, durability, safety, and quality-of-life outcomes of BoNT-A for PAH, with comparative consideration of toxin formulations, injection techniques, and device-based alternatives. Evidence from randomized trials, prospective cohorts, long-term observational studies, and meta-analyses consistently demonstrates that intradermal BoNT-A achieves substantial axillary sweat reduction, often exceeding 50-80%, with improvement of at least two grades on the Hyperhidrosis Disease Severity Scale and meaningful reductions in Dermatology Life Quality Index scores. Treatment effects typically persist for approximately 4-7 months per cycle and are associated with predominantly mild, localized adverse events. Comparative data indicate similar efficacy among onabotulinumtoxinA, incobotulinumtoxinA, and abobotulinumtoxinA when equivalent dosing and standardized mapping techniques are applied. Injection strategy, particularly multi-point intradermal delivery guided by starch-iodine mapping, influences coverage and durability. Energy-based modalities-including microwave thermolysis and fractional microneedle radiofrequency-reduce sweating via device-mediated thermal targeting of eccrine glands and show variable comparative outcomes versus intradermal BoNT-A in durability, downtime, and cost. Overall, BoNT-A remains a well-supported first-line injectable therapy for PAH refractory to topical treatment, while further head-to-head and cost-effectiveness studies remain warranted.

PMID:42602382 | PMC:PMC13474375 | DOI:10.25122/jml-2026-0005

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Associations between Primary Hyperhidrosis and Psychiatric Conditions: A Matched Case-Control Study of 8,508 Patients

Skin Appendage Disord. 2026 Jun 27. doi: 10.1159/000553303. Online ahead of print.

ABSTRACT

INTRODUCTION: Primary hyperhidrosis (PHH) is defined by excess sweating not attributable to medications or underlying medical conditions. It is associated with significant burden of subsequent psychiatric comorbidities, but psychiatric conditions preceding PHH diagnosis are not well characterized. We assessed associations of PHH with preceding psychiatric conditions using a matched case-control approach.

METHODS: Overall, 1,418 participants with PHH and 7,090 matched controls were assessed using the All of Us Research Program database. Multivariable logistic regressions calculated odds ratios and 95% confidence intervals, with Benjamini-Hochberg correction for multiple testing.

RESULTS: Subjects with PHH vs. controls had higher odds of prior diagnosis with obsessive-compulsive disorder (OCD) (OR: 1.97, 95% CI: 1.29-2.94, corrected p = 0.007), restless legs syndrome (RLS) (OR: 1.63, 95% CI: 1.22-2.15, corrected p = 0.007), attention-deficit/hyperactivity disorder (ADHD) (OR: 1.35, 95% CI: 1.07-1.69, corrected p = 0.035), and insomnia (OR: 1.22, 95% CI: 1.04-1.44, corrected p = 0.037).

CONCLUSION: We found significant associations with subsequent PHH diagnosis in participants with OCD, ADHD, RLS, and insomnia. Further research into the etiologies of psychiatric conditions and PHH may better elucidate their relationship.

PMID:42583460 | PMC:PMC13461199 | DOI:10.1159/000553303

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Real-World Outcomes of Microwave Treatment for Axillary Hyperhidrosis and Bromhidrosis: A 12-Month Study in a Southeast Asian Setting

Clin Cosmet Investig Dermatol. 2026 Jul 25;19:617844. doi: 10.2147/CCID.S617844. eCollection 2026.

ABSTRACT

BACKGROUND: Microwave therapy has emerged as a minimally invasive treatment option, but long-term real-world data, particularly from Southeast Asian populations, remain limited.

PURPOSE: To evaluate the effectiveness of microwave therapy and its impact on quality of life (QoL) in patients with axillary hyperhidrosis and bromhidrosis.

PATIENTS AND METHODS: A longitudinal ambispective case series study was conducted on 52 adult patients with axillary hyperhidrosis and bromhidrosis treated with microwave therapy. Treatment efficacy and QoL improvement were assessed at 1 week and at 3, 6, 9, and 12 months post-intervention using the Minor test, Hyperhidrosis Disease Severity Scale (HDSS), Visual Analog Scale (VAS), and Dermatology Life Quality Index (DLQI). Repeated measures were analyzed using mixed-effects models.

RESULTS: At 1 week, the mean area of discoloration decreased markedly from 49.1 cm2 to 0.3 cm2 in the left axilla, with similar improvement observed in the right axilla. At 12 months, compared with baseline, the model-predicted probability of HDSS grade 4 decreased from 68.2% to 5.7%, while the mean odor score and DLQI score decreased from 6.8 to 3.0 and from 19.5 to 6.5, respectively. Overall satisfaction at 12 months was 66.6%. Statistically significant improvements were observed across the majority of efficacy outcomes (p < 0.05). The most common adverse events were pain and swelling, which were mild and self-limiting, with no serious complications reported.

CONCLUSION: Microwave therapy demonstrated a favorable safety profile and sustained clinical benefits in patients with axillary hyperhidrosis and bromhidrosis over 12 months of follow-up. Although patient satisfaction declined modestly at 12 months, overall treatment outcomes remained favorable.

PMID:42529744 | PMC:PMC13418893 | DOI:10.2147/CCID.S617844

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A neurocutaneous Na(V)1.8 channelopathy underlies a genetic subtype of primary idiopathic hyperhidrosis

Sci Adv. 2026 Jul 17;12(29):eaed3221. doi: 10.1126/sciadv.aed3221. Epub 2026 Jul 17.

ABSTRACT

Primary idiopathic hyperhidrosis (PIH) is a poorly understood disorder characterized by excessive sweating. We identify a genetically defined subset of PIH associated with rare coding changes in voltage-gated Na+ (NaV) channels. Whole-exome sequencing of hereditary PIH families revealed gene-level enrichment within the NaV channel family, with SCN10A (NaV1.8) most strongly implicated. A knock-in mouse carrying the clinically observed NaV1.8p.R14L substitution recapitulated excessive sweating. NaV1.8 was detected in a subset of postganglionic neurons in thoracic sympathetic ganglia in humans and mice, where p.R14L produced a gain-of-function profile that enhanced cholinergic responsiveness. Excessive sweating in mutant mice was reversible with NaV channel inhibition, including clinically used agents and a NaV1.8-preferential compound. Together, these findings define a targetable neurocutaneous channelopathy underlying a subset of PIH and support a model in which excessive sweating arises from either gland-intrinsic dysfunction or altered sympathetic drive, motivating stratified therapeutic approaches.

PMID:42467787 | DOI:10.1126/sciadv.aed3221

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The prevalence of depression among patients with primary hyperhidrosis: a systematic review and meta-analysis

BMC Psychol. 2026 Jul 15. doi: 10.1186/s40359-026-05109-w. Online ahead of print.

ABSTRACT

BACKGROUND: A well-established clinical association is recognized between primary hyperhidrosis (PH) and depression. However, the evidence about the prevalence of depression among people with PH is inconsistent, and there is currently no systematic review on the subject.

METHODS: This study systematically searched PubMed, Cochrane Library, Embase, Ovid MEDLINE, Web of Science, and PsycINFO for studies reporting on the prevalence of depression in people with PH from database inception to December 19, 2025. We included cross-sectional and cohort studies reporting depression prevalence, as well as case-control studies reporting depression proportions, in patients with primary hyperhidrosis (PH). Two reviewers independently performed literature screening and data extraction, and assessed methodological quality using the Joanna Briggs Institute (JBI) tool. Following the resolution of any discrepancies by discussion or a third reviewer, the pooled prevalence was derived using a random‑effects model with the Freeman-Tukey double arcsine transformation. Subsequently, subgroup and sensitivity analyses were performed, and publication bias was assessed.

RESULTS: A total of 18 studies published between 2001 and 2024 were included, encompassing 47,053 participants. The overall pooled prevalence of depression was 18.0% (95% CI: 14.3%-22.0%) under the random‑effects model, with substantial between‑study heterogeneity (I2 = 90.24%). Subgroup analyses identified that the reported prevalence of depression varied significantly based on the assessment instrument employed (p < 0.001 for between‑subgroup heterogeneity).

CONCLUSION: This systematic review and meta-analysis demonstrate that depressive symptoms are highly prevalent among patients with primary hyperhidrosis (18.0% as assessed by validated scales), which is substantially higher than the estimated 4.4% global prevalence of clinically diagnosed major depressive disorder in the general population. Although this comparison should be interpreted cautiously, as these estimates are based on different definitions and are not directly comparable, the magnitude of the difference highlights the substantial burden of depressive symptoms in this population. The variation in reported prevalence rates attributable to different assessment tools highlights the necessity of adopting standardized and comparable measurement methods in clinical practice and future research. These findings provide updated evidence on the prevalence of depression in the PH population, identify assessment tools as a major contributor to heterogeneity, and offer valuable guidance for clinical assessment and research design.

TRIAL REGISTRATION: The study protocol was prospectively registered with PROSPERO (CRD42025642265; 24 January 2025).

PMID:42458641 | DOI:10.1186/s40359-026-05109-w

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A retrospective study comparing T3 ganglionectomy and R4 sympathicotomy for reducing compensatory hyperhidrosis in primary palmar hyperhidrosis

J Thorac Dis. 2026 Jun 30;18(6):592. doi: 10.21037/jtd-2026-0904. Epub 2026 Jun 26.

ABSTRACT

BACKGROUND: Despite the high surgical success rate, postoperative compensatory hyperhidrosis (CH) remains a persistent concern in the treatment of primary palmar hyperhidrosis using endoscopic thoracic sympathectomy (ETS). This study aims to compare the early clinical outcomes of two surgical techniques-T3 ganglionectomy and R4 sympathicotomy-to determine which approach minimizes CH occurrence and enhances patient satisfaction.

METHODS: A retrospective analysis of medical records was conducted on patients who underwent either T3 ganglionectomy or R4 sympathicotomy for primary palmar hyperhidrosis at Gangnam Severance Hospital from January 2023 to December 2023. Demographic data and postoperative outcomes were evaluated. CH and degree of satisfaction were assessed during outpatient visits at 3 weeks and 3 months after surgery.

RESULTS: In this study, 44 patients underwent T3 ganglionectomy and 225 patients underwent R4 sympathicotomy. There were no statistically significant differences in baseline characteristics (age, sex, body mass index, smoking history, and family history) or operative complications between the two groups. However, CH at 3 weeks and 3 months after surgery was significantly lower in T3 ganglionectomy group [4 (9.1%) vs. 143 (63.6%); P<0.001, 5 (11.4%) vs. 150 (66.7%); P<0.001]. Additionally, patient satisfaction was significantly higher in the T3 ganglionectomy group compared to the R4 sympathicotomy group (P<0.001).

CONCLUSIONS: T3 ganglionectomy exhibited superior surgical outcomes in terms of both CH and patient satisfaction for primary palmar hyperhidrosis when compared to R4 sympathicotomy. Nonetheless, a larger prospective study with long-term follow-up is necessary to validate these findings.

PMID:42444879 | PMC:PMC13358477 | DOI:10.21037/jtd-2026-0904

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Clinical Characteristics and Treatment Patterns of Hyperhidrosis in Northern Hokkaido: A Single-Center Retrospective Descriptive Study

J Dermatol. 2026 Jul 1. doi: 10.1111/1346-8138.70373. Online ahead of print.

ABSTRACT

Hyperhidrosis is a common condition associated with a substantial negative impact on the quality of life. Several studies have described the clinical characteristics and disease burden of patients with hyperhidrosis in Japan. However, comparable real-world clinical data on hyperhidrosis from Hokkaido remain limited. We therefore evaluated real-world clinical practice patterns at our institution before and after the establishment of a specialized outpatient clinic for hyperhidrosis. In this retrospective study, we analyzed the data of 144 patients who presented with hyperhidrosis between November 2013 and March 2025. Patient characteristics, pathways to care, treatment modalities, and treatment continuation were evaluated using data from electronic medical records. The sex distribution, age at presentation, and subtype distribution of hyperhidrosis in our cohort were largely consistent with those reported in a prior nationwide survey. Primary axillary and/or palmar hyperhidrosis accounted for 87.5% of all cases. After launching a specialized clinic in April 2023, we observed a substantial increase in the number of patients who consulted for hyperhidrosis during visits for other dermatologic conditions; this finding may suggest the presence of previously unrecognized patients. However, changes in hospital access policies may also have influenced consultation patterns. The treatment continuation rates for axillary and palmar hyperhidrosis were both approximately 40%. Among the treatments for axillary hyperhidrosis, sofpironium bromide gel was prescribed most frequently, whereas glycopyrronium tosylate hydrate wipes showed a higher treatment continuation rate. In conclusion, the presence of a specialized outpatient clinic may improve access to care for patients with primary focal hyperhidrosis and facilitate the identification of previously unrecognized patients. However, treatment continuation remained suboptimal, highlighting the importance of improving continuity of care in hyperhidrosis management at our institution.

PMID:42385158 | DOI:10.1111/1346-8138.70373

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T2-sparing vs T2-including sympathectomy for hyperhidrosis: a meta-analysis on compensatory sweating

J Cardiothorac Surg. 2026 Jun 25;21(1):445. doi: 10.1186/s13019-026-04464-4.

ABSTRACT

BACKGROUND: Sympathectomy is the definitive treatment for primary hyperhidrosis, offering high success rates. However, compensatory sweating (CS) remains a frequent and distressing complication. The level of ganglionic resection, particularly the inclusion of T2, may influence CS incidence, but evidence remains inconsistent.

METHODS: A systematic search of PubMed, Embase, and the Cochrane Library was conducted up to July 2025, to identify studies comparing T2-sparing versus T2-including sympathectomy for primary hyperhidrosis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed using the I2 statistic. For outcomes with significant heterogeneity, leave-one-out sensitivity analyses were performed.

RESULTS: Eleven studies involving 3,090 patients were included. Of these, 47.2% underwent T2-sparing sympathectomy and 52.8% underwent T2-including procedures. T2-sparing sympathectomy was associated with a significantly lower incidence of overall CS (OR 0.38; 95% CI 0.21-0.67; p = 0.0009; I2 = 65%) and severe CS (OR 0.43; 95% CI 0.28-0.64; p < 0.0001; I2 = 19%). Subgroup analyses confirmed consistent results across both randomized and non-randomized studies, as well as across short-term (≤ 12 months) and long-term (> 12 months) follow-up periods. Sensitivity analyses confirmed the robustness of the findings. No publication bias was detected.

CONCLUSIONS: T2-sparing sympathectomy was associated with a significantly lower incidence of CS. These findings support avoiding T2 when feasible to minimize postoperative morbidity. Further prospective studies are needed to confirm these results.

PMID:42351253 | DOI:10.1186/s13019-026-04464-4