QHow do you approach botox for hyperhidrosis on the forehead and how do you counsel patients regarding treatment duration?

Botox for hyperhidrosis is getting quite popular with the explosion of social media. In the past patients would get shocked when I would mention it as a treatment option, but now they schedule an appointment specifically for that. Currently only approved for axillary hyperhidrosis, the toxin has grown popularity in areas such as hands, feet, forehead and scalp. We are all familiar with the typical botox treatment patterns for forehead lines, however the dosing for forehead hyperhidrosis is typically higher, ranging from 40 to 80 units.

Some patients can get the procedure covered by insurance after failing oral and topical treatment options, in which case they typically are approved for 100 units. Injection points depend on the length of their forehead, concentrated areas of sweating, and whether or not they have scalp sweating, or heavy eyebrows. I typically place around 40-50 units distributed between their forehead, glabella and lateral edge of their eyebrow in order to prevent heavy eyebrows by lifting them through relaxation of the corrugator and orbicularis oculi. The remaining units are injected on the hairline and upwards towards the scalp.

I always have patients follow up two weeks after treatment top assure they have a symmetrical facial expression and evaluate treatment efficacy. If the patient is already in an oral anticholinergic I have them continue this medication until that follow up and reassess need for titration or potentially discontinue it.

Effects typically begin at around 2 weeks and can last anywhere between 12 and 36 weeks, the latter being less common. The patient satisfaction is tremendous and combined with a good cosmetic eye can lead to a drastic improvement in quality of life.

References:

1. Offidani et.al. Botulinum toxin Type A for treatment of forehead hyperhidrosis: Multicenter Clinical Experience and Review from literature. Toxins, 2022 Jun;14(6):372