Fig. 3: Intradermal botulinum toxin injections for the treatment of palmar hyperhidrosis. For palmar hyperhidrosis, intradermal injections spaced about 1–2 cm apart seem to give the best results. About 2 units of botulinum toxin A are injected per site as required, with a total dose of 100 units for each palm. The main limitation is that most patients find the injections painful and may require regional anesthesia via median, ulnar and radial nerve blocks at the wrist level. A similar technique and dosage of botulinum toxin A is used for the treatment of plantar hyperhidrosis, requiring regional nerve blocks of posterior tibial and sural nerves for anesthesia. Other methods of reducing the pain of injections have included high-intensity vibration devices, cool packs and liquid nitrogen spray, all with variable results.¹³