An avalanche of indications that extend beyond the known profound cosmetic benefits can be derived by BTX use [ 22 ]. Based on the results of this meta-analysis, it could be inferred that BTX injections seem to be superior over the use of placebo. Our study results showed promising implications for patients seeking medical help in practice for the treatment of hyperhidrosis.
For patients with debilitating hyperhidrosis and psychosocial distress, likely refractory to first line treatment, a significant sweat reduction may certainly represent a profound effect. Even though these effects were derived from trials with limited patient cohorts and moderate quality evidence, the differences in severity scores indicate that BTX could significantly improve overall disease severity and quality-of-life.
Neither BTX effects nor quality-of-life or safety outcomes were available for long-term evaluation. Our results are accordingly limited to the first 8 weeks after initial injection. Therefore, the long-term determination of treatment effect would still be warranted in the future.
Current guidelines recommend BTX application after failure of topical agents [ 23 ]; however, study data suggest its superior efficacy in hyperhidrosis patients in comparison with first line topical treatments. Due to the lack of efficacy comparison with other treatment agents, conclusions cannot be drawn from our analysis to adjust the order of treatment modalities and the role of BTX injections.
However, the confidence in the efficacy of the alternative treatment options is arguably no greater than that for BTX. Despite its significant treatment effect and appropriate safety profile, common downsides need to be considered when administering BTX in the treatment of hyperhidrosis.
Treatment costs are still high in comparison with readily available topical and systemic agents, especially when considering the necessity of multiple injections over the course of longer treatment periods. In our analysis, the lack of direct comparisons with other treatment modalities prevents the evaluation of cost effectiveness of the BTX treatment.
Were it not for the significantly higher costs, it would probably be recommended earlier for hyperhidrosis care. Besides, the pain induced by injections, particularly in sensitive areas such as the palms or axillae, can negatively impact patient comfort and tolerance, as well as long-term adherence [ 7 ].
Given the chronic character of the disease and the requirement for multiple injections during the course of the long-term treatment, transdermal BTX applications may be of interest in the future [ 24 , 25 ].
Additionally, the minimal risk of anaphylactoid reactions and the risk of muscle atrophy with subsequent intramuscular fat deposition should always be born in mind and discussed with the patient prior to injection [ 26 , 27 ]. Skilled injections and substantial knowledge of anatomical target sites are therefore of utmost importance for safe application. Studies included in our analysis generally depict that BTX has a substantial safety profile and the results from all included trials that evaluated adverse events agree with those assertions.
Nonetheless, given current guidelines on the treatment of hyperhidrosis, BTX therapy remains one of the most well-studied treatment options for focal hyperhidrosis and remains a solid treatment modality following unsuccessful initial topical treatment.
Of note, a total of three BTX A products are cleared for the treatment of axillary hyperhidrosis, whereas the treatment of other focal sites has yet to be approved, rendering any such treatment currently off-label [ 28 ]. Further research on the efficacy of BTX injections is warranted in order to extend its approval and broader application for various focal sites affected by hyperhidrosis.
Regarding the limitations of this meta-analysis, a large-scale and adequately powered randomized controlled trial analyzing the effectiveness of BTX in comparison with established treatment modalities such as topical treatments, iontophoresis and surgical options would be warranted. Additionally, further comparative studies with radiofrequency thermotherapy and fractional microneedle radiofrequency in hyperhidrosis may also be warranted.
Rummaneethorn et al. Our data suggest that BTX effectively yields superior results for patients with hyperhidrosis in terms of subjective and quantitative analysis compared to placebo. However, the limited quality of evidence needs to be considered. Despite there being no gold standard in the treatment of hyperhidrosis, the current therapy scheme advocated recommends the use of BTX after the failure of conventional therapy.
However, given its significant anhidrotic superiority over placebo injections, initial BTX treatment may be a good option in clinically severe cases in order to improve treatment response and to avoid unwarranted patient dissatisfaction. General downsides to consider in comparison with treatment alternatives would be discomfort as a result of injection-pain and substantially higher treatment costs. This article does not include any studies with human participants or animals performed by any of the authors.
Doha Obed and Mustafa Salim share first authorship. Publisher's Note. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. National Center for Biotechnology Information , U. Aesthetic Plastic Surgery. Aesthetic Plast Surg. Published online Feb Bingoel , 1 Thurid R. Hofmann , 1 Peter M. Vogt , 1 and Nicco Krezdorn 1. Alperen S. Thurid R. Peter M.
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