Subcutaneous curettage vs. injection of botulinum toxin A for treatment of axillary hyperhidrosis

Background Axillary hyperhidrosis is a functional non-inflammatory abnormality of the eccrine sweat glands. The cause of genuine hyperhidrosis is unknown and, therefore, no specific corrective therapy is available and conservative treatment often fails. Subcutaneous sweat gland curettage of the axillae is one of the proven surgical modalities. Local injection of botulinum toxin A (BT-A) is a promising new conservative approach. Objective The purpose of this study was to compare the efficacy of subcutaneous curettage vs. injection of BT-A in axillary hyperhidrosis. Methods A total of 113 patients (36.3% males, 63.7% females) suffering from genuine axillary hyperhidrosis were treated by either subcutaneous curettage (n = 90) or local injection of BT-A (n = 23). Median follow-up period was 23.5 months. Questionnaires were handed out to patients for a subjective assessment of symptoms before treatment, 6 months after the procedure, and at the time of last follow-up. The patients were asked to rate the amount of axillary sweating based on a score ranging from 1 (no axillary secretion) to 6 (maximum axillary secretion). The subjective scores of sweating at rest, at high temperatures, under physical stress, under emotional stress and after spicy meals were assessed. Results The patients' subjective assessments of the overall outcome after subcutaneous curettage were 'very good' in 36.4%, 'good' in 29.9% and 'satisfactory' in 16.9%. The subjective score of axillary sweating at rest was reduced to 40.0% after 6 months, and finally to 45.7% at the end of follow-up (median: 28.2 months). Patients treated by BT-A injection assessed outcome as 'very good' in 39.1%, 'good' in 21.7% and 'satisfactory' in 8.7%. Sweating at rest was reduced to 48.5% after 6 months, and finally to 68.8% at the end of follow-up (median: 16.1 months). The mean duration of the antiperspiration effect of BT-A was 7.6 months (median: 7 months), but there were two cases of long durations, i.e. 14 and 18 months. Conclusions Subcutaneous curettage and injection of BT-A both present major advantages compared with earlier methods. Subcutaneous curettage offers the same permanent efficacy but far fewer side-effects than sympathectomy, and less scarring than local excisional procedures, respectively. Of the conservative approaches BT-A is by far the most efficacious. Patients should be informed of the advantages and disadvantages of both methods.