OnabotulinumtoxinA Injections (Botox®)
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. (For complete prescribing information for Botox for hyperhidrosis, click here.)
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.
Research demonstrates that treating excessive sweating of the armpits, hands, feet, head and face (craniofacial), and other relatively small body areas (like under the breasts or in the groin area) with onabotulinumtoxinA is safe and effective. When used to treat underarm excessive sweating, Botox has been shown to result in an 82-87% decrease in sweating. Results start to be noticeable approximately 2 to 4 days after treatment with the full effects usually noted within 2 weeks. Dryness typically lasts 4 to 12 months, but some studies have found it can last as long as 14 months. Additional statistics from published research studies have shown that repeated treatment with Botox is safe and effective for hyperhidrosis and consistently results in meaningful, long-lasting improvements in an excessive sweating patient’s symptoms, daily functioning, and quality of life. Botox treatment for hyperhidrosis has also been scientifically proven to improve on-the-job productivity. While sweating is an essential body function for temperature control, localized body areas house only a small percentage of the body's sweat glands (the underarms, for instance, are home to less than 2% of the body’s sweat glands.) The temporary cessation of these sweat glands' functioning, therefore, has little to do with body thermoregulation. Compensatory sweating (sweating on other body parts, common after ETS surgery) has not been found to be a concern.
In the case of palmar (hand) excessive sweating, research shows that Botox is 80-90% effective. Repeat injections are needed after 6 months. Botox for palmar sweating may cause temporary pain and weakness in the hands.
Botox injections work well on the head and face, but the injection technique requires skill, so patients should seek an experienced practitioner. A potential side effect of Botox injections in the face as a treatment for sweating is asymmetry, particularly of the forehead. This can happen if some of the Botox diffuses into the facial muscles. Such asymmetry, however, is always temporary and can, if necessary, be balanced out by additional Botox injections.
Botox can also be used for plantar hyperhidrosis (excessive sweating of the feet), but patients report more pain during plantar injections and statistics indicate the treatment is less effective than when used for other body sites; indeed, some data suggests that 50% of patients are dissatisfied with the results.
There are multiple forms of botulinum toxin-A on the market. Conversion ratios between the brandnames Botox (onabotulinum toxin-A), Dysport (abobotulinum toxin-A) and Xeomin (incobotulinum toxin A) in practice, according to an article in the journal Toxins are:
Botox and Xeomin - 1:1 (dose equivalent units)
Botox/Xeomin and Dysport - 1:2-3
According to the Cleveland Clinic, results may last longer and manifest faster with Xeomin and there may be fewer allergic reactions to Xeomin. Xeomin does not need to be refrigerated. Dysport may diffuse further or spread more. Effects of Dysport can last about the same as Botox, but with Dysport effects are visible at about 2 days compared to about 1 week with Botox. With all three injectables, FULL results will take a week or two to manifest. Of course, results vary from individual to individual as well. Prices for the three injectables vary from practice to practice. Which botulinum toxin might be right for you? Weigh the pros and cons of each with your healthcare provider.
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.
Zinc dietary supplements may be able to improve your botulinum toxin treatment results. There’s not a lot of data on this, and more studies are needed, but some doctors recommend taking zinc daily for four or five days prior to botulinum toxin injections and on the day of the injections. After that, it’s no longer useful, they say, until the days leading up to your next injections. The theory is that zinc may impact how the neurotoxin binds to its target neurotransmitters and can help botulinum toxin results to last longer than they would otherwise. In one study, zinc was shown to prolong the effects of treatment with botulinum toxin by 30%. These results have been met with some skepticism, however, so it’s best to talk to your healthcare provider about whether zinc could be useful for you, or not. To find a hyperhidrosis-aware clinician, visit our Clinician Finder.
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.
Hopefully, botulinum toxin resistance does not happen to you - remember it’s rare! - but if it does, please also remember that there are other treatments for hyperhidrosis available and you can find healthcare providers to help using our Clinician Finder.
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. If you are seeking financial assistance for axillary hyperhidrosis treatment with Botox specifically, see our Botox Insurance Help page.
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Research and References
Ready to learn more about Botox for the treatment of excessive sweating? See the below links for relevant scientific research. More hyperhidrosis-related publications can be found here.
Elgendy YS, Elzoghby S, AbuBakr N. Effect of zinc or copper supplementation on the efficacy and sustainability of botulinum toxin A "Botox" injection in masseter muscle of albino rats. J Stomatol Oral Maxillofac Surg. 2025 Oct;126(5):102156. doi: 10.1016/j.jormas.2024.102156. Epub 2024 Nov 15. PMID: 39550001.
Koshy JC, Sharabi SE, Feldman EM, Hollier LH Jr, Patrinely JR, Soparkar CN. Effect of dietary zinc and phytase supplementation on botulinum toxin treatments. J Drugs Dermatol. 2012 Apr;11(4):507-12. PMID: 22453589.