Botulinum toxin

onaA, aboA or incoA shown to have similar efficacy/safety

Doses below for onaA

  • Axillary: 50-100 units/axilla (10–20 injection sites spaced 1.5–2 cm apart)
  • Palmar: 50-200 units/palm (among 50–100 injection sites)
  • Plantar: 50-200 units/sole
  • Forehead/scalp: 50-100 units
  • Frequency of injections: every 4-6 months

Inhibition at neuromuscular junction: cleaves SNARE proteins blocking pre-synaptic acetylcholine release leading to reduction in sweat

Absolute

  • Allergy 
  • Skin infection 

Relative

  • Pregnancy/lactation
  • Peripheral motor neuropathic diseases

  • Anaphylaxis (rare)
  • Pain, swelling, erythema, bruising, headache
  • Weakness of underlying muscles (e.g. hand weakness, brow/lip ptosis, etc.); typically, resolves
  • Exacerbation of neuromuscular disease

Increased effects if given with drugs that interfere with neuromuscular transmission

  • Aminoglycosides
  • Muscle relaxants

  • Onset within 4-10 days
  • Lasts 5-9 months 
  • Used for palmoplantar, forehead and axillary hyperhidrosis 
  • Starch-iodine testing pre-operatively to localize sites involved 
  • Pregnancy category C