Prior authorization is recommended. To authorize, call Blue Cross and Blue Shield of Montana (BCBSMT) Customer Service at 1-800-447-7828 or fax your request to the Medical Review Department at 406-441-4624. A retrospective review is performed if services are not prior authorized.
When the criteria for coverage is not met, BCBSMT encourages all participating providers to have a member complete and sign an Advanced Member Notification (AMN) form stating that BCBSMT will not cover this service, supply, device, or drug. If an AMN is signed prior to delivery of the service, participating providers can balance bill the patient. If an AMN is not signed, participating providers are financially liable and cannot balance bill the BCBSMT member for denied services. Services provided by an out-of-state provider that are denied as not medically necessary are the financial responsibility of the patient even if an AMN is signed.
Refer to the Advanced Member Notification medical policy for more information. The AMN form is available at www.bcbsmt.com (Click on Providers and then Forms).
BCBSMT considers the following treatments investigational as a treatment for severe gustatory hyperhidrosis including, but not limited to:
- Botulinum toxin is considered investigational for treatment of gustatory hyperhidrosis. (See Policy Guidelines for list of conditions)
- Microwave treatment is considered investigational for primary focal hyperhidrosis.
Federal mandate prohibits denial of any drug, device or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.
In the absence of evidence to the contrary, botulinum toxin products are considered to have a class effect. This approach is consistent with policy; Botulinum Toxin.
A multispecialty working group defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months’ duration without apparent cause and with at least 2 of the following features: bilateral and relatively symmetric sweating, impairment of daily activities, frequency of at least once per week, age at onset younger than 25 years, positive family history, and cessation of focal sweating during sleep. (1)
In the hyperhidrosis disease severity scale, patients rate the severity of symptoms on a scale of 1-4 (2):
- My underarm sweating is never noticeable and never interferes with my daily activities.
- My underarm sweating is tolerable but sometimes interferes with my daily activities.
- My underarm sweating is barely tolerable and frequently interferes with my daily activities.
- My underarm sweating is intolerable and always interferes with my daily activities.
A variety of iontophoretic devices can be purchased for use in the home. There are no specific HCPCS codes for these pieces of DME [durable medical equipment]. Code E1399 (Durable medical equipment, miscellaneous)
Botulinum toxin may be coded for using HCPCS codes:
- J0585 Injection, onabotulinumtoxinA, 1 unit
- J0586 Injection, abobotulinumtoxinA, 5 units
- J0587 Injection, rimabotulinumtoxinB, 100 units
- J0588 Injection, incobotulinumtoxinA, 1 unit
Gustatory hyperhidrosis conditions:
- Frey’s syndrome
- diabetic neuropathies
- herpes zoster parotitis
- parotid abscess
This policy was updated regularly with searches of the MEDLINE database. The most recent literature search was performed for the period February 2011 through February 2012. Following is a summary of the key literature to date:
The published literature regarding iontophoresis as a treatment of hyperhidrosis is sparse. A 2003 TEC Assessment on iontophoresis concluded that the evidence was insufficient to determine whether the effects of iontophoresis for the treatment of hyperhidrosis exceed those of placebo. (3) The investigators identified only 3 small studies (n=10, 11, and 18, respectively), all of which were conducted in patients with palmar hyperhidrosis. The TEC Assessment also concluded that, in the treatment of hyperhidrosis, the evidence is insufficient to draw conclusions about the relative effectiveness of iontopheresis using tap water compared to topical drug administration. No randomized controlled trials (RCTs) evaluating iontophoresis for treating hyperhidrosis have been published since the 2003 TEC Assessment.
Conclusion: There is insufficient evidence that iontophoresis is an effective treatment of hyperhidrosis.
Botulinum toxin type A
A considerable body of published literature addresses botulinum toxin injection of the treatment of axillary and palmar hyperhidrosis and substantiates the efficacy of this treatment. (4-15) Studies include multiple randomized placebo-controlled trials evaluating Botox, a botulinum toxin type A product. In addition, another botulinum toxin A product, Dysport, has been evaluated in RCTs for treatment of axillary hyperhidrosis (13) and palmar hyperhidrosis. (11) Moreover, a small RCT published in 2007 compared Botox and Dysport and found similar levels of efficacy and safety with the two products. (5)
One of the larger RCTs was published in 2007. (14) This study was an industry-sponsored multicenter double-blind, placebo-controlled efficacy and safety study of botulinum toxin type A in patients with persistent bilateral primary axillary hyperhidrosis. Enrollment criteria included a resting sweat production of at least 50 mg/axilla in 5 minutes and a rating of 3 or 4 (underarm sweating barely tolerable or intolerable, and frequently or always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS). A total of 322 patients were randomized to receive 50 U, or 75 U of Botox or placebo. Retreatment after 4 weeks was allowed in subjects with at least 50 mg of sweat (per axilla) over 5 minutes and an HDSS score of 3 or 4. Following the first injection, 75% of subjects in the Botox groups showed at least a 2-point improvement in the HDSS, compared with 25% of subjects in the placebo group. Sweat production decreased by 87% (75 U), 82% (50 U), and 33% (vehicle). (Similar results were obtained in patients requiring a second treatment.) The median duration of effect was 197, 205, and 96 days (75 U, 50 U, and vehicle, respectively). Seventy-eight percent of subjects (252) completed the 52-week study; 96 of 110 (87%) in the 75-U group, 83 of 104 (80%) in the 50-U group, and 73 of 108 (68%) in the control group. Intent-to-treat analysis at 52 weeks showed a responder rate (greater than 2-point improvement on the HDSS) for 54 (49%) subjects in the 75-U group, 57 (55%) in the 50-U group, and 6 (6%) in the placebo group. Injection-site pain was reported in about 10% of all groups, with a mean duration of 2.4 days (10-day maximum).
No placebo-controlled RCTs were identified evaluating the safety and efficacy of the newest formulation of botulinum toxin A, Xeomin. In 2010, Dressler published a double-blind RCT from Germany comparing Xeomin to Botox for treating primary axillary hyperhidrosis. (16) Forty-six patients with bilateral axillary hyperhidrosis and a previously stable Botox treatment for at least 2 years received 50 MU of Botox in one axilla and 50 MU Xeomin in the other axilla. All patients completed the study. A total of 41 of 46 (89%) patients reported the therapeutic effect as excellent and 5 (11%) as good. The mean reported duration of therapeutic effect was 3.2 months. According to patient self-report in structured interviews, there were no side-to-side differences in therapeutic effect including onset latency, extent and duration and no differences in injection site pain. Moreover, clinical examination did not identify any side-to-side differences in the diffuse sweating pattern.
There is less evidence in support of botulinum toxin type A for treating plantar hyperhidrosis. No RCTs or large uncontrolled studies were identified; most published studies are case reports or small case series.
The evidence evaluating botulinum toxin A use for gustatory hyperhidrosis as a result of Frey’s syndrome includes noncontrolled or nonrandomized studies, all showing favorable treatment outcomes. The patient inclusion criteria were variable across the studies and case reports; ages varied (16 to 87 years); patients had undergone varied types of parotid surgery (i.e., bilateral, partial); not all studies documented gustatory sweating with Minor’s starch test as part of the patient screening.
Conclusions: Multiple RCTs support the efficacy and safety of botulinum toxin A for treating severe axillary and palmar hyperhidrosis. There is a lack of RCTs on use of botulinum toxin A for plantar hyperhidrosis and gustatory hyperhidrosis.
Botulinum toxin type B
There was one placebo-controlled randomized trial on botulinum toxin B (Myobloc) for treating primary axillary hyperhidrosis and one on palmar hyperhidrosis. Both studies were by Baumann and colleagues and were published in 2005; neither discussed whether patients had failed previous treatments for hyperhidrosis. The study on axillary hyperhidrosis included 20 participants; they received subcutaneous injections of Myobloc (2,500 U or 0.5 mL per axilla) (n=15) or placebo (n=5). (17) Patients who received placebo were offered Myobloc at subsequent injections. One patient in the placebo group did not return for follow-up and another responded to placebo and did not return for a subsequent Myobloc injection. Data were available on Myobloc efficacy for the remaining 18 participants (15 in the initial Myobloc group and 3 crossovers). There was a statistically significant improvement in axillary hyperhidrosis according to patient and physician subjective assessment from baseline (before receiving an active injection) to Day 30. Details on the efficacy outcomes were not reported. The mean length of time to return to baseline levels of sweating in these 18 patients was 151 days (range 66 to 243 days). Sixteen participants reported 61 adverse events over the course of the study. Five of 61 adverse events (8.2%) were determined to be definitely related to the study; 4 axillary bruising events and 1 instance of pain at the injection site. Eleven adverse events (18%) were determined to be probably related to study treatment; dry eyes (n=3), dry mouth (n=5) and indigestion (n=3). Flu-like symptoms were reported by 6 of 20 patients (30%); however, the study period coincided with flu season. Note that the authors did not compare the active treatment and placebo groups in their analysis.
The RCT on Myobloc for treatment of palmar hyperhidrosis included 20 participants with excessive palmar sweating. Fifteen participants received injections of Myobloc (50,000 U per palm) and 5 received placebo. (18) Nonresponders were offered an injection of Myobloc at day 30. At day 30, the two quality-of-life measures were significantly higher in the Myobloc group compared to the control group. However, there was not a statistically significant difference in efficacy in the physician analysis of the palmar iodine starch test at day 30 (p=0.56). No further details were provided on the efficacy outcome measures described above. The mean duration of action according to self-report in 17 patients (15 in the initial treatment group and 2 who crossed-over from the placebo group) was 3.8 months (range, 2.3 to 4.9 months). Participants were asked about specific adverse events. Eighteen of 20 (90%) reported dry mouth/throat, 12 (60%) reported indigestion, 12 (60%) reported excessively dry hands, 12 (60%) reported muscle weakness, and 10 (50%) reported decreased grip strength. Both studies by Baumann and colleagues were limited by a small sample sizes and limited or no comparative data.
A small randomized trial by Frasson and colleagues in Italy that compared botulinum toxin type A and type B for treating axillary hyperhidrosis was published in 2011. (19) This study included 10 patients with idiopathic focal axillary hyperhidrosis that was unresponsive to other non-surgical treatments. Patients received 50 U botulinum toxin A in one axilla and 2,500 U botulinum toxin B in the contralateral axilla. Gravimetry was performed at baseline and follow-up as an objective measurement of sweat production. In addition, the sweat area was photographed. At each follow-up point, the decrease in sweat weight from baseline was significantly greater on the botulinum toxin B side compared to the botulinum toxin A side. For example, after 1 month, the sweat weight in 5 minutes was 13% of the baseline value on the botulinum toxin A side and 4% of the baseline value on the botulinum toxin B side (p=0.049). By 6 months, the sweat weight returned to 91% of baseline on the botulinum toxin A side and 56% of baseline weight on the botulinum toxin B side (p=0.02). Findings were similar for sweating area. All patients tolerated injections of botulinum toxin types A and B well and none reported systemic adverse effects. The authors commented that this study used a higher dosage of botulinum toxin B than previous studies.
Conclusions: There are few RCTs evaluating botulinum toxin type B for treating hyperhidrosis. One small RCT did not clearly demonstrate the efficacy of botulinum toxin type B in patients with palmar hyperhidrosis. Two RCTs support the efficacy of this treatment for patients with axillary hyperhidrosis.
A 2012 RCT evaluated a microwave device for treating hyperhidrosis. (20) This device applies microwave energy to superficial skin structures with the intent of inducing thermolysis of the eccrine and apocrine sweat glands. This industry-sponsored double-blind study randomized 120 adults with primary axillary hyperhidrosis in a 2-to-1 ratio to active (n=81) or sham (n=39) treatment. Treatment consisted of 2 sessions, separated by approximately 2 weeks. Patients who responded adequately after 1 session or declined further treatment did not need to undergo the second session, and a third procedure was allowed within 30 days for participants who still had a high level of sweating after 2 sessions. All patients in the sham group had 2 sessions. In the active treatment group, 11 individuals (9%) had only 1 session and 10 (8%) had a third procedure. The primary efficacy endpoint was a score of 1 (underarm sweating never noticeable) or 2 (underarm sweating tolerable) on the Hyperhidrosis Disease Severity Scale at the 30-day follow-up; HDSS score at 6 months was a secondary outcome. A total of 101/120 (84%) completed the study. At 30 days, 89% of the active treatment group and 54% of the sham group had an HDSS score of 1 or 2; p<0.001. At 6 months, 67% of the active treatment group and 44% of the sham group had an HDSS score of 1 or 2; the difference between groups remained statistically significant, p=0.02. Unblinding occurred at 6 months. Twelve-month data were available for the active treatment group only; 69% reported an HDSS score of 1 or 2. There were 45 procedure-related adverse events in 23 (28%) of the active treatment group and 5 (13%) of the sham group. The most frequently reported adverse event was altered sensation; no serious adverse events were reported. Compensatory sweating was reported by 2 individuals in each group and had a mean duration of 52 days. The authors noted that study data provided an opportunity to identify areas for improvement of the treatment protocol including waiting longer between treatments and using a higher dose of energy at the second session.
Conclusions: A single RCT provides insufficient evidence that microwave treatment improves the health outcome for primary focal hyperhidrosis. This RCT reports short term benefit of microwave treatment in reducing hyperhidrosis, but also reports a high rate of skin-related side effects such as pain and altered sensation. Additional studies with long-term follow-up in the treatment and control groups, a longer period of blinding, and a consistent treatment protocol are needed to confirm the efficacy of this treatment and to better define the risk/benefit ratio.
Tympanic neurectomy for gustatory hyperhidrosis
Review articles by Clayman et al. (21) and de Bree et al. (22) describe the various medical and surgical treatments for Frey’s syndrome. Tympanic neurectomy is described as a treatment for Frey’s syndrome, with satisfactory control reported in 82% of patients. In addition, this surgical treatment is generally definitive without a need for repeated interventions.
Sweat gland excision for primary focal hyperhidrosis
Surgery may involve removal of the subcutaneous sweat glands without removal of any skin, limited excision of skin, and removal of surrounding subcutaneous sweat glands, or a more radical excision of skin and subcutaneous tissue en bloc. (23) Depending on the completeness of surgical excision, the treatment is effective in 50–95% of patients.
Transthoracic sympathectomy for primary focal hyperhidrosis
Several RCTs and one meta-analysis have compared different approaches to surgery; there were no sham-controlled RCTs. In 2011, Deng and colleagues published a meta-analysis of data from RCTs and observational studies published to 2010 evaluating thoracoscopic sympathectomy for patients with palmar hyperhidrosis. (24) The authors pooled outcome data from different approaches to sympathectomy, i.e., single-ganglia blockage (T2, T3, or T4), and multi-ganglia blockage (T2-3, T2-4, or T3-4). (Note: T refers to rib). Based on these analyses, they concluded that T3 (11 studies) and T3-4 (2 studies) had the “best” clinical efficacy i.e., postoperative resolution of symptoms. The T3 approach resulted in a 97.9% pooled efficacy rate, and the T3-4 approach resulted in a 100% pooled efficacy rate. In the studies for which data were available, the pooled rate of postoperative compensatory sweating was 40% after T3 surgery. Data on compensatory sweating after T3-4 surgery was only available from one study with 60 patients; a pooled analysis could not be performed.
RCTs continue to be published comparing levels of sympathectomy. A 2011 study by Baumgartner and colleagues included 121 patients with disabling palmoplantar hyperhidrosis. (25) Patients were randomized to receive bilateral sympathectomy over T2 (n=61 patients) or T3 (n=60 patients). Six of 121 (5%) patients, 3 in each group, were considered treatment failures i.e., had recurrent palmar sweating to a bothersome level. There were no significant differences between groups in the reported subjective change in plantar or axillary sweating after surgery. At 6 months, the mean level of compensatory sweating (0 to 10 severity scale) was 4.7 (standard deviation [SD]=2.7) for the T2 group and 3.8 (SD=2.8) for the T3 group (p=not significant). Similarly, at 1 year, the mean severity rating of compensatory sweating was 4.7 (SD=2.5) in the T2 group and 3.7 (SD=2.8) in the T3 group; p=0.09. Another study was published by Ishy and colleagues in Brazil in which surgery at the T3 and T4 levels was compared. (26) This study included 20 patients with palmar hyperhidrosis. All patients experienced complete bilateral remission of palmary sweating after 1 year of follow-up. The level of compensatory sweating did not differ significantly between groups at 1 week, 1 month, or 6 months, but at 1 year, there was a significantly higher rate in the T3 compared to the T4 group (20/20, 100% in the T3 group and 15/20, 75% in the T4 group, p=0.47)
There is also a large amount of data from case series on transthoracic sympathectomy for treating primary focal hyperhidrosis. (27-33) Case series generally report high success rates for palmar and axillary hyperhidrosis, although there are potential adverse effects, most commonly compensatory sweating.
For example, in 2010, Wait and colleagues published a retrospective analysis of prospectively collected data on patients who underwent bilateral thoracoscopic sympathectomy for hyperhidrosis. (32) A total of 348 patients underwent surgery; data were available on 322 (93%) of patients. Patients’ previous use of nonsurgical hyperhidrosis treatments was not reported. Complete resolution of symptoms was experienced by 300 of 301 (99.7%) with palmar hyperhidrosis, 136 of 186 (73%) with axillary hyperhidrosis, 27 of 30 (90%) with craniofacial hyperhidrosis, and 19 of 197 (9.6%) with plantar hyperhidrosis. There was a low rate of complications, and most occurred in the first half of the series. Nine patients (2.8%) required chest tube evacuation of a pneumothorax. Seven patients (2.2%) had unilateral Horner’s syndrome; 5 of these were among the first 100 patients. Compensatory sweating was reported by a total of 201 of 322 (62%) patients. The compensatory sweating was severe in 20 (6.2%) of patients and mild or moderate in 181 (56.2%) of patients. It is worth noting that thoracoscopic sympathectomy was performed in some cases of plantar hyperhidrosis and that there was a low rate of success. In addition, when reporting rates of compensatory sweating, the authors did not distinguish between mild and moderate levels of symptoms, although these could have different clinical implications for the patient.
In addition, a large series was published in 2011 by Smidfelt and Drott in Sweden. (33) Of 3,015 patients who had been treated with endoscopic thoracic sympathectomy for hyperhidrosis and/or facial blushing, 1,700 (56%) responded to a written survey after a mean of 14.6 (SD=2.4) years. The most common indications for surgery were palmar hyperhidrosis (n=795, 47%) and facial blushing (n=536, 32%). A total of 85.1% of respondents reported that they had a satisfactory and lasting effect of the surgery. Sweating and/or blushing recurred and was considered a problem in 8.1%, and 6.9% reported no initial effect or a poor effect. No or insignificant compensatory sweating was reported by 425 (25.6%) respondents. Compensatory sweating was considered troublesome by 299 (17.6%), annoying by 409 (24.1%), severe by 367 (21.6%), and incapacitating by 190 (11.2%). Nearly half of the patients who underwent surgery did not respond to the survey; their outcomes may have been different from those of study respondents.
Conclusions: RCTs and a meta-analysis of RCTs support the efficacy of transthoracic sympathectomy at various levels for palmar and axillary hyperhidrosis. These data are complemented by case series which have found high efficacy rates, but also high rates of compensatory sweating for these conditions. There is insufficient evidence in support of transthoracic sympathectomy for treating plantar hyperhidrosis; case series found lower rates of efficacy for plantar compared to axillary or palmar hyperhidrosis, and there are concerns for side effects in sexual functioning.
Endoscopic lumbar sympathectomy for primary plantar hyperhidrosis
No RCTs were identified but several case series were identified. A 2009 series by Rieger and colleagues from Austria evaluated surgery results in 90 patients (59 men, 31 women with severe plantar hyperhidrosis. (34) Thirty-seven patients (41%) had only plantar hyperhidrosis, and 53 (59%) had plantar and palmar hyperhidrosis. All patients had previously used other treatments including topical aluminum chloride therapy. There were a total of 178 procedures–90 on the right-side and 88 on the left side. The technique involved resecting a segment of the sympathetic trunk between the third and fourth lumbar bodies together with the ganglia (L3 and/or L4). After a mean follow-up of 24 months (range: 3 to 45), hyperhidrosis was eliminated in 87 of 90 patients (97%). Postoperative neuralgia occurred in 38 (42%) patients between the seventh and eighth day. The pain lasted less than 4 weeks in 11 patients, 1-3 months in 19 patients, 4-12 months in 5 patients, and more than 12 months in 3 patients. Three men reported temporary sexual symptoms; one was incapable of ejaculation for 2 months. None of the women reported postoperative sexual dysfunction.
In 2010, Reisfeld reported on results of a U.S.-based study from a specialized hyperhidrosis clinic in which bilateral endoscopic lumbar sympathectomy was performed in 63 patients with focal plantar hyperhidrosis. (35) There were 13 (21%) male patients and 50 (79%) female patients. A clamping method was used in which clamps were placed at L3 (46.6%), L4 (52.4%), and L2 in one case. There was a learning curve with this procedure, and 5 early cases had to be converted to an open procedure. Fifty-six (89%) of the patients had previously undergone some form of thoracic sympathectomy, and all had tried conservative measures. After a mean follow-up of 7 months, all patients considered their plantar hyperhidrosis symptoms to be “cured” or “improved;” 97% reported “cure.” All of the patients with previous thoracic sympathectomy had some degree of compensatory sweating. After lumbar sympathectomy, 51 of the 56 patients (91%) reported that their compensatory sweating was unchanged. In the 7 patients who did not have a previous thoracic sympathectomy, 1 reported mild and 6 reported moderate compensatory sweating. The authors stated that no sexual problems were reported by the male patients, and they did not discuss possible sexual problems among the female patients.
It is worth noting, that in contrast to earlier concerns about this procedure being associated with risks of permanent sexual dysfunction in men and women, the recent case series did not find any instances of permanent sexual dysfunction. A 2004 review from a multi-specialty working group on hyperhidrosis stated that lumbar sympathectomy is not recommended for plantar hyperhidrosis because of associated sexual dysfunction; this article did not cite any data documenting sexual dysfunction. (1) To date, there are very few studies on endoscopic lumbar sympathectomy for focal plantar hyperhidrosis and no comparative studies.
Conclusions: There are insufficient data supporting the safety and efficacy of lumbar sympathectomy for treating primary plantar hyperhidrosis.
There is insufficient evidence on the efficacy and safety of iontophoresis or microwave treatment for treating hyperhidrosis. There is evidence from randomized trials that botulinum toxin improves the net health outcome for patients with axillary hyperhidrosis and evidence that botulinum toxin A products improve the net health outcome for palmar hyperhidrosis. Due to the limited number of studies and high rates of adverse effects, there is insufficient evidence that botulinum toxin B improves the net health outcome for patients with primary palmar hyperhidrosis There is insufficient evidence on the efficacy of any botulinum toxin products for other types of primary hyperhidrosis, including plantar and secondary hyperhidrosis.
Regarding surgical treatments for hyperhidrosis, data from randomized controlled trials and observational studies show high rates of efficacy of endoscopic transthoracic sympathectomy for primary focal hyperhidrosis, with the exception of plantar hyperhidrosis. There are, however, high rates of compensatory hyperhidrosis which must be considered in the treatment decision. There are insufficient data to draw conclusions on the efficacy of endoscopic lumbar sympathectomy in patients with primary plantar hyperhidrosis.
Practice Guidelines and Position Statements
In 2011, an expert consensus statement on the surgical treatment of hyperhidrosis was published by a task force of the Society of Thoracic Surgeons. (36) The document states that endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis. They further recommend the following treatment strategies (with R referring to rib and the number to which rib):
- R3 interruption for palmar hyperhidrosis; an R4 interruption is also reasonable. The authors note a slightly higher rate of compensatory sweating with an R3 but R3 is also more effective at treating hyperhidrosis.
- R4 or R5 interruption for palmar-axillary, palmar-axillary-plantar or axillary hyperhidrosis alone; R5 interruption is also an option for axillary hyperhidrosis alone.
- R3 interruption for craniofacial hyperhidrosis without blushing; an R2 and R3 procedure is an option but may lead to a higher rate of compensatory sweating, and also increases the risk of Horner’s syndrome.
In 2008, the American Academy of Neurology (AAN) created guidelines for use of botulinum neurotoxin for the treatment of autonomic disorders and pain. (37) These guidelines include the following recommendations for botulinum toxin injection as a treatment of hyperhidrosis:
- Should be offered as a treatment option to patients with axillary hyperhidrosis (Level A).
- Should be considered as a treatment option for palmar hyperhidrosis and drooling (Level B).
- May be considered for gustatory sweating (Level C).