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Management of Craniofacial Hyperhidrosis with Botulinum Toxin: A Systematic Review

Skin Appendage Disord. 2026 Sep 25. doi: 10.1159/sad/aesag012. Online ahead of print.

ABSTRACT

INTRODUCTION: Treatment of craniofacial hyperhidrosis (CFH) is challenging because of the anatomical characteristics of the head and face. Although topical anticholinergics are generally considered first-line therapy, botulinum toxin has emerged as an effective option, while evidence remains more limited than for axillary hyperhidrosis. The objective of this study is to systematically review current evidence on the efficacy and safety of botulinum toxin in the treatment of CFH.

METHODS: Clinical studies evaluating different types of botulinum toxin type A (BoNT-A) and type B (BoNT-B) for CFH were reviewed, focusing on treatment efficacy, onset of response, anatomical sites and safety.

RESULTS: BoNT-A was the most consistently studied formulation and demonstrated substantial improvement of CFH. The duration of response generally ranged from 4 to 9 months, with more recent cohorts reporting efficacy lasting up to 12 months. Onset of action typically occurred within 1-2 weeks. The forehead and scalp were the most frequently treated sites, followed by gustatory and occipital regions. BoNT-B also produced significant reductions in sweating and improvements in quality of life.

CONCLUSION: Botulinum toxin appears to be an effective and safe treatment for CFH. Long-term studies are needed to establish the optimal toxin type, administration technique and retreatment interval.

PMID:42923985 | PMC:PMC13688397 | DOI:10.1159/sad/aesag012

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Bilateral R2 sympathetic surgery for craniofacial hyperhidrosis: a 10-year retrospective cohort study on long-term outcomes and development of a prognostic predictive model

Surg Endosc. 2026 Oct 20. doi: 10.1007/s00464-026-13521-x. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the long-term efficacy and safety of bilateral R2 sympathetic surgery for CFH, to characterize the 10-year longitudinal trajectory of postoperative CH and recurrence, and to identify clinically accessible predictors of CH and postoperative satisfaction that may assist in preoperative risk communication. Preliminary nomograms were developed and internally validated using the area under the curve (AUC), calibration plots, sensitivity, and specificity.

MATERIALS AND METHODS: A total of 127 patients who underwent bilateral R2 sympathetic surgery for CFH between April 2013 and April 2023 were retrospectively analyzed. Baseline characteristics, operative details, and follow-up outcomes were extracted from medical records and structured telephone interviews. Predictive features were selected using least absolute shrinkage and selection operator (LASSO) regression. Cox proportional hazards and multivariate logistic regression models were subsequently applied to identify independent predictors of CH and satisfaction, respectively. Nomograms were developed and internally validated using the area under the receiver operating characteristic curve (AUC), calibration plots, sensitivity, and specificity.

RESULTS: All patients achieved immediate resolution of craniofacial sweating, accompanied by a significant postoperative heart rate reduction (84.8 ± 11.68 → 72.17 ± 7.54 bpm, P < 0.001). Severe CH (grade IV) developed in 70.1% of patients, predominantly involving the thoracoabdominal (84.3%) and thigh (54.3%) regions. Cox regression identified preoperative heart rate > 79.5 bpm (HR = 2.46, 95% CI 1.61-3.75, P = 0.0002) and sympathetic clamping (HR = 5.69, 95% CI 3.03-10.67, P = 0.001) as independent risk factors for severe CH. Logistic regression showed that lower preoperative thoracoabdominal sweating was associated with higher postoperative satisfaction (OR = 0.05, 95% CI 0.01-0.23, P = 0.001). The nomograms demonstrated adequate discrimination and calibration.

CONCLUSION: Bilateral R2 sympathetic surgery achieves rapid and durable relief of craniofacial hyperhidrosis with sustained high satisfaction over 10 years. Beyond confirming efficacy, the extended follow-up uniquely demonstrates that CH severity stabilizes within the first postoperative year and does not worsen over time-a critical finding for patient reassurance. Preoperative resting heart rate > 79.5 bpm and the use of sympathetic clamping independently predict severe CH, whereas lower baseline thoracoabdominal sweating predicts superior satisfaction. Although the proposed nomograms require external validation before routine adoption, they offer a practical, individualized reference for preoperative risk communication and, combined with the intraoperative choice of electrocautery, support a dual-phase strategy for optimizing surgical outcomes in CFH patients.

PMID:42902000 | DOI:10.1007/s00464-026-13521-x

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Treatment Satisfaction and Patterns Among Primary Hyperhidrosis Patients

J Dermatol. 2026 Oct 19. doi: 10.1111/1346-8138.70539. Online ahead of print.

ABSTRACT

Primary hyperhidrosis can substantially impair daily activities and psychosocial well-being. This single-center cross-sectional questionnaire study examined treatment use and factors associated with treatment satisfaction among 92 patients with primary hyperhidrosis recruited by treating physicians at a single clinic between 2024 and 2025. Treatment use was analyzed at the patient-treatment level using logistic regression with patient-level clustering. Factors associated with treatment satisfaction were evaluated using generalized estimating equation logistic regression, and sensitivity analyses applied alternative satisfaction thresholds. Patient-reported sweat reduction was the factor most consistently associated with treatment satisfaction. This association remained evident in adjusted models and sensitivity analyses. In contrast, time to treatment effect, hyperhidrosis disease severity scale score, sex, age group, treatment-related adverse events, treatment modality, and affected site showed no statistically significant or consistent associations with satisfaction. Sweat reduction and satisfaction wasn’t completely concordant; some observations indicated satisfaction despite poor sweat reduction, whereas dissatisfaction despite favorable sweat reduction was rare. Treatment frequency showed no consistent association with satisfaction, and treatment duration differed only under one strict definition of satisfaction. Although affected site was not independently associated with satisfaction in the regression models, descriptive satisfaction rates varied across body-site and treatment-modality combinations. Patient-reported sweat reduction did not fully explain treatment satisfaction. Treatment benefit should therefore be assessed comprehensively by considering perceived sweat reduction, treatment burden, and broader clinical context.

PMID:42897084 | DOI:10.1111/1346-8138.70539

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Topical oxybutynin antiperspirant for axillary hyperhidrosis: a phase IIb PROBE design clinical trial (TODAY trial)

J Vasc Bras. 2026 Sep 14;25:e20250065. doi: 10.1590/1677-5449.20250065. eCollection 2026.

ABSTRACT

BACKGROUND: Primary hyperhidrosis is a chronic condition with limited therapeutic options.

OBJECTIVES: To evaluate the impact of 10% oxybutynin spray on axillary hyperhidrosis, considering both its local and systemic effects, in terms of Hyperhidrosis Disease Severity Scale (HDSS) outcomes for hyperhidrosis of the axilla and eight additional sites.

METHODS: Prospective phase II PROBE design trial. Adult patients with axillary hyperhidrosis were randomized to receive a 10% oxybutynin topical spray, oral oxybutynin, or placebo spray for 35 days. Efficacy was evaluated on day 35 using the HDSS and a hyperhidrosis-specific quality-of-life (QoL) assessment questionnaire.

RESULTS: 17 patients were randomized. No significant differences were observed in HDSS outcomes from baseline to day 35 in any of the three groups (2.5 [2 – 4], 4 [3 – 4], 3.5 [3 – 4], p= 0.207), although a trend to improvement was noted in both treatment groups. Significant improvement in the QoL questionnaire was observed from baseline to day 35 in the oxybutynin spray group (pre-intervention QoL: 78.5 [70 – 96] and post-intervention QoL: 38.5 [32 – 67], p = 0.031).

CONCLUSIONS: No differences were observed in the primary outcome. A significant improvement from baseline to day 35 was observed in the QoL questionnaire score for the oxybutynin spray group.

PMID:42890128 | PMC:PMC13671017 | DOI:10.1590/1677-5449.20250065

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Efficacy of Radiofrequency Combined with Chemical Sympatholysis in the Treatment of Primary Palmar Hyperhidrosis: A Retrospective Cohort Study

J Vasc Interv Radiol. 2026 Oct 14:109135. doi: 10.1016/j.jvir.2026.109135. Online ahead of print.

ABSTRACT

PURPOSE: To investigate and compare the efficacy and safety of radiofrequency thermocoagulation (RFT) and combined with chemical sympatholysis (RFT-CS) for the treatment of primary palmar hyperhidrosis (PPH) (Hyperhidrosis Disease Severity Scale [HDSS] grade III or IV).

MATERIALS AND METHODS: Patients who underwent computed tomography-guided percutaneous thoracic sympathetic neurolysis (TSN) for PPH were retrospectively analyzed and divided into two treatment regimens: RFT (group RFT, N = 60, 120 sides) and RFT combined with CS (group RFT-CS, N = 58, 116 sides).

RESULTS: At 1, 3, 6, 12, and 24 months, the number of sides with HDSS III/IV in the RFT group was 29, 32, 41, 47, and 56, respectively; in the RFT-CS group, 25, 31, 36, 40, and 45, with no statistically significant intergroup differences at any time point (all P ≥ .05). Overall recurrence rates rose from 3.0% at 1 month to 19.5% at 24 months, with no significant differences between groups at any time point (all P ≥ .05). The RFT-CS group had significantly higher compensatory hyperhidrosis (CH) rates at 12 months (62.1% vs. 56.7%; P = .012) and 24 months (58.6% vs. 50.0%; P = .014), and a higher incidence of thoracic neuralgia at 1 month (P = .023) and 3 months (P = .011).

CONCLUSION: Both of the TSN treatment modes are effective for the treatment of severe PPH. Compared with RFT alone, RFT combined with CS does not seem to show better efficacy but increases the occurrence of CH and thoracic neuralgia.

PMID:42874704 | DOI:10.1016/j.jvir.2026.109135

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Robotic selective thoracic sympathectomy for hyperhidrosis: refined technique and anatomical variation

Multimed Man Cardiothorac Surg. 2026 Oct 14;2026. doi: 10.1510/mmcts.2026.094.

ABSTRACT

Primary hyperhidrosis substantially impairs quality of life. Conventional sympathectomy risks compensatory hyperhidrosis through trunk disruption, whilst selective sympathectomy preserves the trunk while dividing preganglionic and postganglionic fibres. We describe a technique refinement and a previously undescribed anatomical variant. A 23-year-old man had severe refractory palmar, axillary, plantar and gustatory hyperhidrosis (SSDS 4) profoundly affecting his confidence, social functioning and mental wellbeing, despite conservative management. He underwent staged bilateral robotic selective dorsal thoracic sympathectomy. Preganglionic and postganglionic fibres were divided from the top of T2 to T4 with trunk preservation. Refinements included resection from the top of the second rib, minimal diathermy with sharp dissection and non-touch technique using Maryland bipolar forceps. On the right, a postganglionic ramus ascending retrogradely from a displaced T3 ganglion into the third intercostal space was identified, previously undescribed in the literature, requiring dissection across the fourth rib to prevent hypothesized residual axillary hyperhidrosis. Both stages were completed 1 month apart, drain-free, with next-day discharge. There was complete symptom resolution, no Horner’s syndrome and no compensatory hyperhidrosis at follow-up.

PMID:42872462 | DOI:10.1510/mmcts.2026.094

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Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: ten-year clinical outcomes and a phenomenology-informed interpretation of body experience

Psychol Health Med. 2026 Oct 12:1-21. doi: 10.1080/13548506.2026.2746787. Online ahead of print.

ABSTRACT

Primary focal hyperhidrosis (PFH) is a chronic condition of excessive sweating disproportionate to thermoregulatory need, with substantial social and occupational burden. We evaluated outcomes of endoscopic thoracic sympathectomy (ETS)-symptom severity, quality of life, satisfaction, compensatory hyperhidrosis (CH), and recurrence-and interpreted dissatisfaction among patients who developed CH through a phenomenological lens. This retrospective single-centre cohort study included 72 patients who underwent ETS for PFH between January 2013 and December 2021, assessed preoperatively and at years one and five using the HDSS, DLQI, and Gillespie satisfaction scale. Sympathectomy level, technique, CH, recurrence, and psychosocial avoidance behaviours were recorded. Normality was rejected on Shapiro-Wilk testing; Wilcoxon signed-rank, Mann-Whitney U, chi-square, and Fisher’s exact tests were applied, with effect sizes as rank-biserial correlation (r) and Cramér’s V. The study received ethics approval (3 June 2026-39804) and adheres to the STROBE checklist. The cohort comprised 72 patients (44 male/28 female; mean age 22.8 ± 5.2 years; disease duration 7.3 ± 2.8 years). Palmar localisation predominated (63.9%); 90.3% avoided handshaking preoperatively. Mean HDSS declined from 3.29 ± 0.74 to 1.65 ± 0.96 at year five (p<0.001;r = 0.83); 61.5% reached HDSS = 1. Mean DLQI fell from 3.83 ± 0.67 to 1.94 ± 1.07 (p<0.001;r = 0.84); DLQI≥4 dropped from 68.1% to 7.7%. Five-year satisfaction was 76.6%. CH developed in 13 patients (18.1%), graded by level-T2 72.7%, T3 10.4%, T3-T4 0%(χ2 = 26.98;p<0.001; V = 0.61). Five-year DLQI was 3.23 ± 1.17 with CH versus 1.62 ± 0.77 without (p<0.001;r = 0.73); 84.6% of CH patients were undecided or regretful versus 7.8% without (p<0.001). Recurrence was 5.6%. ETS achieves durable symptom control and well-preserved long-term satisfaction in PFH. Marked dissatisfaction among patients who develop CH indicates that body-related awareness and social functioning are, for a meaningful subset, as decisive as physiological control. T2 sympathectomy should be reserved for clear anatomical indications, and informed consent should address the lived significance of CH beyond statistical risk disclosure.

PMID:42861922 | DOI:10.1080/13548506.2026.2746787

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Radiofrequency Ablation for Refractory Palmar and Plantar Hyperhidrosis: A Case Report

Anesth Pain Med. 2026 Feb 28;16(1):e172975. doi: 10.5812/aapm-172975. eCollection 2026 Feb 28.

ABSTRACT

INTRODUCTION: Palmar and plantar hyperhidrosis (PH) is characterized by sweat production that far exceeds thermoregulatory needs and often has substantial effects on daily functioning, social interaction, and mental health. The condition results from sympathetically mediated overstimulation of the eccrine glands, which are innervated by unmyelinated cholinergic C-type fibers. Radiofrequency ablation (RFA) offers a minimally invasive approach to symptom control in refractory PH through heat-mediated disruption of these sympathetic fibers. Reports describing staged upper- and lower-limb RFA for combined palmar and plantar disease in a single patient remain uncommon; this is the primary reason for presenting this case.

CASE PRESENTATION: A 21-year-old man (American Society of Anesthesiologists physical status I) presented with a 10-year history of progressive palmar and plantar hyperhidrosis that had not shown durable responses to conservative or prior interventional treatment. He used topical aluminum chloride for 2 months without meaningful benefit and subsequently underwent 2 sessions of palmar botulinum toxin injections 5 months apart, which reduced palmar sweating by an estimated 50 – 60% for approximately 2 months per session; the lower limbs were not treated. Eighteen months before the current admission, he underwent RFA of the right thoracic sympathetic chain at another center. This produced approximately 80% improvement in palmar sweating, although sweating persisted along the ulnar nerve distribution; the benefit lasted only approximately 4 months, after which symptoms recurred to baseline. During the present admission, staged RFA was performed bilaterally at L3, with different lower-limb protocols selected in advance based on the prior treatment response and the greater severity of plantar sweating on the left. Seven days later, bilateral RFA was performed at T3. At the 2-week, 1-month, and 7-month follow-up visits, the patient reported no compensatory sweating or change in cutaneous sensation. By his own assessment, overall sweating of the palms and soles was reduced by approximately 90% from baseline, with a satisfaction score of 9/10 and subjectively improved quality of life.

CONCLUSIONS: Staged RFA targeting both the thoracic and lumbar sympathetic chains appears to be a reasonably safe palliative option for patients with refractory combined palmar and plantar hyperhidrosis, with a more favorable complication profile than surgical sympathectomy. This case is considered reportable because it involves combined, staged treatment of both the upper and lower limbs in a single patient.

PMID:42763681 | PMC:PMC13589454 | DOI:10.5812/aapm-172975

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Primary Hyperhidrosis: A Review of Epidemiology, Pathophysiology and Management

Acta Derm Venereol. 2026 Sep 16;106. doi: 10.2340/actadv.v106.adv-2026-0770.

ABSTRACT

Primary hyperhidrosis is termed as excessive sweating exceeding the physiological needs of thermoregulation. This review provides an updated overview focusing on epidemiology, quality of life, pathophysiology, economic impacts, diagnostic approaches and current management strategies. A literature search was conducted in June 2026 across PubMed and the Cochrane Central Register of Controlled Trials. Additional references were identified through manual searches of relevant bibliographies. Reported prevalence of hyperhidrosis varied widely, likely reflecting differences in methodology and disease recognition. Primary hyperhidrosis is associated with autonomic dys-regulation involving sympathetic pathways. Emerging evidence suggests that molecular alterations in eccrine glands may represent secondary adap-tations to sustained cholinergic stimulation, while genetic variability in receptor expression may contribute to interindividual differences in disease severity. Hyperhidrosis has a strong negative impact on the economy and quality of life, adversely affecting both mental and physical health. Multiple treatment options are available, including topical therapies, systemic agents, device-based interventions, botulinum toxin injections, and surgery. Despite increasing recognition of the clinical burden, comprehensive economic evaluations remain limited, with indirect costs and long-term societal impact insufficiently characterized. In conclusion, primary hyperhidrosis imposes a substantial burden on affected individuals, requiring improved re-cognition, standardized diagnostic frameworks, and individualized management strategies supported by high-quality and longitudinal research.

PMID:42747166 | DOI:10.2340/actadv.v106.adv-2026-0770