Over the years, it has become accepted practice to use Botox injections to treat hyperhidrosis of the underarms (this is the hyperhidrosis use for which Botox was FDA-approved). In fact, underarm, or axillary, hyperhidrosis is the most common form of hyperhidrosis to be treated with Botox. But more and more physicians -- and particularly dermatologists -- are also learning injection techniques for the treatment of palmar hyperhidrosis (excessive sweating of the palms), sweaty feet, and profuse sweating of the face and head. Additionally, dermatologists are pioneering the treatment of other excessively sweaty localized (or relatively small) body areas such as areas in the groin, under the breasts, and on the back or chest. To get information about these breakthroughs in the treatment of "not-as-typical" hyperhidrotic areas of the body, we talked to Dr. Nowell Solish, a founding member of the International Hyperhidrosis Society's Board of Directors and a renowned North American hyperhidrosis expert.
Dr. Nowell Solish is Assistant Professor of Dermatology at the University of Toronto and past president of the Canadian Society for Dermatologic Surgery. In his Toronto dermatology practice at the Sunnybrook and Women's Health Science Centre, he has successfully used Botox to treat excessive sweating in the groin, under the breasts, between the breasts, on the lower back, upper lip, and nose.
In terms of technique, says Dr. Solish, "It's a matter of depth [of the injections]" on different body areas. For instance, he says, when injecting Botox in the face, one must be conscious of the underlying muscles and avoiding a negative cosmetic effect. For the groin, Dr. Solish assures us that the injections do not affect sexual function as they are usually given along the crease of the groin and leg, towards the rectal area, and not near any muscles that would have an impact on sexual function. (One might argue, however, that the confidence boost derived from the relief of groin sweating may have a positive impact on sexual function.)
When considering an excessively sweating area for Botox injections, Dr. Solish says that the limiting factor is often the size of the area, the amount of Botox required to inject the area, the cost of that Botox, and the time to do the injections. "Consider this," says Dr. Solish, "One vial of Botox usually is enough to treat one hand. When you start trying to inject more than two vials -- meaning that you're trying to cover a body area that's larger than the size of two hands -- it starts to get impractical."
As of June 2018, there is a new treatment option for hyperhidrosis from Dermira Inc called Qbrexza. Qbrexza (pronounced kew brex' zah) was FDA-approved for the underarms and is expected to be available in October 2018. It comes in individually packaged cloths or wipes that can be used at home once per day to reduce sweating. The treatment works by blocking receptors responsible for sweat gland activation. The active ingredient in Qbrexza is glycopyrronium tosylate, an anticholinergic formulation.
Will healthcare providers feel that it is appropriate to use Qbrexza “off-label” for other body areas? As you may know, Botox is only FDA-approved for hyperhidrosis of the underarms and is often used for other purposes. And oral anticholinergics are not FDA-approved for hyperhidrosis treatment but are often prescribed off-label for excessive sweating patients. We have heard from multiple dermatologists who think there will “certainly” be off-label use of Qbrexza, but one cautions that facial use may run the risk of getting the treatment in the eyes and that the skin on the hands and feet may be too thick for adequate absorption of the active ingredients… But perhaps it will be a good choice for other areas of the body? We will update this page as information becomes available.
In research studies of Qbrexza, the most common side effects were:
- Dry mouth (in 16.9-24.2% of patients)
- Erythema/area redness (in 17% of patients)
- Burning/stinging (in 14.1% of patients)
Qbrexza was shown in clinical trials to improve underarm sweating symptoms as soon as 1 week after starting the regimen. Studies also found that patients using Qbrexza wipes once daily for four weeks improved their underarm “sweating severity” by nearly 25% to 30% (compared with 4% to 5% with placebo) and that measured sweat volume was reduced by 50% or more (in most patients.) The wipes were well-tolerated, and any reported side effects were primarily mild to moderate (see above). Qbrexza is FDA-approved for patients with extreme underarm sweating who are 9 years or older. Talk to your healthcare provider about whether Qbrexza might be a good choice for you, or not. It will be available starting October 2018.
Powders for Sweat Management
Baby powder or talcum powder as well as other powders are common products found in medicine cabinets and retail pharmacies worldwide. Recently, however, studies have raised concerns that the use of talc-based powder in the genital area may increase risk of ovarian cancer in women. Additionally, many pediatricians advise that powders be avoided around babies due to the risks of powder inhalation.
In terms of hyperhidrosis and sweat management, particularly in the groin, where does this leave us?
Dr. Adelaide A. Hebert, Professor, University of Texas Medical School at Houston and a founding member of the International Hyperhidrosis Society, says that she has never been a big recommender of talcum powder, except maybe for use on the feet, and never for babies.
Light powder use, says Dr. Hebert, if there is no family history of ovarian cancer, on the inner thighs (but not in the genital area), and by men (unless exposure to the genitals of a female sexual partner is a concern) is probably fine.
Still, Dr. Hebert prefers other more effective treatments for groin sweating, such as the oral medications Robinul or oxybutynin (both anticholinergics) or Botox injections. She also sees promise in topical anticholinergics currently in development and encourages patients to consider joining clinical trials to help bring new treatments to market through research. The best way to find hyperhidrosis trials that need patient-participants is to watch this page and our social media.
“We are coming to an era in hyperhidrosis care where there will be alternatives to current medications,” says Dr. Hebert, “offering patients choices they can feel safe using; without having to use talc.”
“It’s not as clear cut [regarding talc and ovarian cancer] as it may seem,” adds Dr. Samantha Hill, a pediatric dermatologist in Virginia, hyperhidrosis expert, and International Hyperhidrosis Society faculty member, “However, because there are non-talc alternatives for sweating, we should avoid talc when possible.” Dr. Hill recommends Botox injections, glycopyrrolate (anticholinergic) topical wipes, oral glycopyrrolate, or the antiperspirant gel Hydrosal to her patients with groin sweating.
For Physicians: Botox Injection Training for Various Focal Sweating Areas
Physicians wishing to introduce themselves to the technique of Botox injections for hyperhidrosis of both non-typical and typical body areas, or to review and improve their skills, should attend one of our upcoming continuing medical education programs. But if you can't make it or want a refresher, review valuable skills and techniques online with the International Hyperhidrosis Society's Video Library. Recently-released videos are now available with demonstrations and explanations are given by International Hyperhidrosis Society Board of Directors members Dr. David Pariser, former president of the American Academy of Dermatology, and Dr. Dee Anna Glaser, Professor of Dermatology and Vice-Chairman, Department of Dermatology, Saint Louis University School of Medicine. The new videos include important research statistics, tips to ensure successful treatment, step-by-step detailed demonstrations and instructions, and much more. Whether HCPs would like to improve professional skills in injecting Botox for axillary, craniofacial, palmar, plantar, or submammary (sweating under the breasts) hyperhidrosis, our Video Library is the place to start.
As with other online materials related to a learned medical skill, these videos are designed to help physicians prepare for hyperhidrosis by continuing medical education events or other training, or as a review after training. Each technique discussed and demonstrated in the videos requires proper training and background -- such as that provided at International Hyperhidrosis Society continuing medical education events. Comprehensive, day-long programs are held periodically and include live demonstrations and hands-on skills training.
Nothing about hyperhidrosis is really typical, but with more physicians learning to treat non-typical body areas with Botox through the resources we make available online and at our CME programs, patients with unexpected hyperhidrotic body areas can get the treatment they need to feel normal or "typical" again. Which has a huge impact on their happiness and quality of life.