Hyperhidrosis, or excessive sweating, can constitute a significant inconvenience in daily life, both functionally and psychologically. When it is localized and resistant to conventional treatments, botulinum toxin injection—commercially known as Botox®—represents an effective, validated, and well-tolerated therapeutic alternative. However, this treatment is not suitable for everyone.
It is therefore essential to precisely define the selection criteria for candidates for botulinum toxin treatment in hyperhidrosis, in order to optimize its efficacy while ensuring the safety of the medical procedure.
The first fundamental criterion is the presence of primary localized hyperhidrosis—that is, not related to an underlying disease—and sufficiently bothersome to impact quality of life. Botox is primarily indicated in the following cases :
Before considering treatment with botulinum toxin, it is recommended that the patient first use first-line therapies, such as aluminum salt-based antiperspirants or iontophoresis. In cases of insufficient efficacy or intolerance, botulinum toxin injections then represent a relevant therapeutic alternative.
The severity of hyperhidrosis is not measured solely by the amount of sweat produced, but also by its impact on the patient’s life. A good candidate for Botox is often someone whose excessive sweating interferes with :
Assessment scales such as the HDSS (Hyperhidrosis Disease Severity Scale) can be used in consultation to objectify this discomfort. A high score on this scale is a good indicator for recommending Botox treatment.
Botulinum toxin treatment is generally well tolerated, but it is not suitable for all patients. Certain medical contraindications must be strictly ruled out during the pre-treatment evaluation :
A thorough clinical evaluation allows verification of the absence of these factors. The doctor also ensures the absence of secondary hyperhidrosis, which would require a different type of treatment.
A good candidate for Botox is also an informed and motivated person, who understands the mechanism of action of the treatment, its benefits, its limitations, as well as the need to repeat the treatment every six months. Contrary to some common misconceptions, Botox does not permanently eliminate sweating: its effect is temporary, with an average efficacy of 4 to 6 months depending on the treated area.
It is therefore important that the patient :
This cooperative profile promotes optimal management and high therapeutic satisfaction.
In summary, a good candidate for Botox is generally :
The use of Botox in the treatment of localized hyperhidrosis should not be seen as the only solution, but rather as a rational therapeutic step, often proposed after the failure of less invasive or less costly treatments.
Aluminum hexahydrate salt-based antiperspirants (often at 20%) are the first-line treatment. They act by temporarily blocking the sweat gland ducts. Although effective in some patients, these products have several limitations: frequent skin irritation, variable effectiveness depending on the area (ineffective on hands or feet), and a temporary effect often limited to a few hours.
Iontophoresis consists of passing a low-intensity electrical current through skin immersed in water, in order to temporarily block the activity of the sweat glands. Effective mainly on hands and feet, this method requires repeated sessions (often several times a week), strict compliance from the patient, and the use of specific equipment.
In comparison, botulinum toxin treatment provides significant improvement with an injection frequency of about once every 5 to 6 months, making it more compatible with daily and professional life constraints.
Some physicians prescribe anticholinergics (glycopyrrolate, oxybutynin) in cases of diffuse or resistant hyperhidrosis. Their effectiveness can be acceptable, but they often cause bothersome side effects: severe dry mouth, visual disturbances, constipation, concentration problems, or drowsiness.
Botox, as a local treatment, avoids systemic effects while providing targeted and predictable relief.
In the most extreme cases of resistant palmar hyperhidrosis, endoscopic thoracic sympathectomy may be considered. This surgical procedure involves cutting the nerve fibers responsible for excessive sweating. While it can be effective, it carries several risks: compensatory sweating (often severe) on other parts of the body, persistent chest pain, pneumothorax, or neurological complications.
Botox is therefore clearly preferable before considering any invasive or irreversible solution, especially due to its temporary, reversible, and customizable nature.
The question of reimbursement is legitimate, given the sometimes disabling impact of hyperhidrosis. However, coverage for botulinum toxin treatment depends on the location of hyperhidrosis.
In Switzerland, treatment of severe axillary hyperhidrosis with Botox injections can be partially covered by basic health insurance (LAMal), provided that the diagnosis is well documented, first-line treatments have failed, and the treatment is performed by a physician.
A medical report and a coverage request may be required. Patients are advised to check directly with their insurance provider for the exact reimbursement procedures.
However, for other locations (palmar, plantar, facial, etc.), coverage is generally excluded, except in very particular cases with a well-documented medical dossier.
Article written by Dr Romano Valeria
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