Primary Focal Facial and Gustatory

The general recommendation is to try more-conservative therapy before resorting to invasive treatment. Each of the anatomic areas with excessive sweating is more or less susceptible to the various approaches available.[9]

Gustatory sweating (Frey’s syndrome) can be controlled in part by avoiding foods known to stimulate sweating. Such foods commonly include coffee and other caffeinated products, chocolate, spicy or sour foods, hot foods, alcohol, foods or drinks containing citric acid, and/or sweets.[19,83,145] If avoidance of triggers provides the patient with insufficient relief, systemic medications may be considered.

If a patient presents with primary focal facial hyperhidrosis that occurs during anxiety-provoking situations (such as public speaking) or is exacerbated by such situations, short-term expectant use of a benzodiazepine or anticholinergic can be considered. [9,19]

For those patients who experience frequent facial or cranial sweating (sweating that is not relieved by expectant use of a systemic medication), the next line of treatment is botulinum toxin A (BTX-A) with injections repeated as necessary to provide continued relief. [80,84] Patients who do not respond to BTX-A, or who are averse to the procedure, may try topical antiperspirant therapy provided that they are educated in proper application in order to avoid skin irritation.

The treatment of last resort for facial sweating is ETS but the evidence that ETS is effective for this indication comes from a small series of patients and the surgery is not as effective for facial/cranial sweating as for palmar sweating. [6,112]