Journal of Cosmetic Dermatology, 12, 232--234

OnabotulinumtoxinA therapy for compensatory hyperhidrosis

Jessica A Adefusika, BS,1 & Jerry D Brewer, MD2

1Mayo Medical School, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA2Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota, USA

Summary Background Compensatory hyperhidrosis due to the treatment for focal primary

hyperhidrosis can be devastating and life-altering.

Objective The purpose of this paper is to discuss use of the iodine starch test and

dilute botulinum toxin to decrease compensatory hyperhidrosis over large surface

areas.

Methods A large area of the trunk affected by compensatory hyperhidrosis was

treated with dilute botulinum toxin therapy using a starch iodine test for localization.

Results The patient had exceptional results with his compensatory truncal sweating

returning to normal and remaining stable for multiple months.

Conclusion Treating compensatory hyperhidrosis of large surface areas with dilute

botulinum toxin therapy is effective and safe.

Keywords: compensatory hyperhidrosis, onabotulinumtoxinA, sympathotomy

Introduction

Primary focal hyperhidrosis is characterized by exces-

sive production of sweat, mainly in the axillae, palms,

soles, and forehead, in disproportion to that required

for thermoregulation. The prevalence of hyperhidrosis

ranges from 0.6% to 2.8%1,2 with 50% of cases being

axillary hyperhidrosis.2 Patients with hyperhidrosis are

often adversely affected in their daily activities, social

life, and professional life. Although thoracic sympa-

thectomy (removal of sympathetic chain) has histori-

cally been considered an effective treatment for upper

limb hyperhidrosis, Atkinson et al.3 suggested sympath-

otomy (disconnection of the sympathetic trunk via

cautery, clamps etc., without removal of the sympa-

thetic chain) as a more successful approach to treating

hyperhidrosis. Despite the efficacy of both surgical pro-

cedures in treating primary hyperhidrosis, the most

common and troublesome adverse effect is compensa-

tory hyperhidrosis (CH), most frequently in the trunk.

Compensatory hyperhidrosis, compared with primary

hyperhidrosis, can be debilitating and negatively

impact quality of life. Severe intolerable CH, where

patients often have to change their clothes during the

day, occurs more frequently in patients who under-

went sympathectomy (about 35%) than sympathotomy

(1.3%).3–6 Limited treatment options have been pro-

posed for CH, and the overall results have been disap-

pointing, with the exception of subcutaneous injections

of onabotulinumtoxinA.5,7 OnabotulinumtoxinA is

emerging as a reliable, well-tolerated CH treatment.

Case report

A 49-year-old man underwent a T2 sympathotomy for

flushing in 2003 at another facility. Severe compensa-

tory hyperhidrosis of the trunk, mostly on his chest

and back, developed subsequently. He had no known

hyperhidrosis prior to the procedure. The clamp was

removed 6 months after sympathotomy, with the hope

of diminishing compensatory sweating; however, the

*Correspondence: J D Brewer, MD, Division of Dermatologic Surgery,

Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail: brewer.

jerry@mayo.edu

Accepted for publication January 24, 2013

232 © 2013 Wiley Periodicals, Inc.

Back to Basics

symptoms persisted. CH became a considerable problem

in the patient’s life, affecting him socially and psycho-

logically. After 8 years of unsuccessful medical treat-

ments, he was referred to our clinic.

A starch iodine sweat test indicated positive areas of

sweat, particularly on his upper chest and also on his

upper abdomen (Fig. 1). The patient was treated with

300 units of onabotulinumtoxinA reconstituted in

15 mL of saline. Approximately, 150 injection sites

were mapped with two units of onabotulinumtoxinA

to each site.

At 3-month follow-up, the upper back (Fig. 2) and

upper abdominal areas (Fig. 3) were treated with 400

units of onabotulinumtoxinA, with each of 100 units

diluted with 5 mL of normal saline. The patient contin-

ued to note considerable improvement at the 5-month

visit.

Discussion

Compensatory hyperhidrosis is the most common

long-term adverse effect and the leading cause of dis-

satisfaction after surgical treatment for hyperhidrosis

or blushing. The mechanism by which CH occurs is

unclear, and no predictive factors have been eluci-

dated. Some studies suggest the location of the pri-

mary hyperhidrosis, sympathectomy level, and clamp

vs. cut vs. resection technique not only cause CH but

also contribute to its frequency and severity.8,9 Severe

CH may be more devastating than primary hyperhi-

drosis, and thus, there is great demand for CH treat-

ments with high long-term efficacy and no adverse

effects.

OnabotulinumtoxinA has been proven useful in

treating primary hyperhidrosis; however, only a few

case reports and an uncontrolled case series of 17

patients have examined its performance and safety in

treating CH. Kim et al.5 reported an effective treat-

ment for severe truncal sweating using higher doses

of onabotulinumtoxinA with no complaints of sys-

temic adverse effects. Another study suggested the

combination of onabotulinumtoxinA with video-

assisted extension of the sympathectomy yields suc-

cessful CH treatment.10 In the patient described here,

we used onabotulinumtoxinA diluted with 5 mL per

100 units to be able to treat a large surface area and

achieved subsequent anhidrosis. Despite the cost of

onabotulinumtoxinA, given the rarity of such severe

CH and this patient’s interest in annual treatments,

onabotulinumtoxinA seems reasonable in this and

similar situations.

In conclusion, CH can be effectively treated with

subcutaneous injections of onabotulinumtoxinA. This

case demonstrates the successful treatment for CH

using onabotulinumtoxinA in a large surface area

with minimal discomfort and no notable adverse

effects.Figure 1 Starch iodine test depicting increased compensatory

hyperhidrosis on the chest.

Figure 2 Increased compensatory hyperhidrosis on the back at

rest. This patient typically sweated through three to five shirts

per day.

Figure 3 After the first onabotulinumtoxinA session, the

patient’s chest showed decreased hidrosis.

© 2013 Wiley Periodicals, Inc. 233

Compensatory hyperhidrosis therapy . J A Adefusika & J D Brewer

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234 © 2013 Wiley Periodicals, Inc.

Compensatory hyperhidrosis therapy . J A Adefusika & J D Brewer