Botulinum toxin and hyperhidrosis of the amputation stump in war amputees


Najla Mouhli
Meriem Hfaidh
Achraf Abdennadher
Kais Ben Amor
Hajer Rahali
Khalil Amri
Rim Maaoui


Introduction: Stump hyperhidrosis is a common condition after lower limb amputation. It affects the prosthesis use, and the quality of life of patients. Several case reports tried to prove benefit of using Botulinum toxin in its treatment.

Aim: This study was to conduct a larger workforce clinical trial and to demonstrate benefits of botulinum toxin injection in the treatment of stump hyperhidrosis.

Methods: A prospective study was conducted. War amputees who complained of annoying excessive sweating of the stump were included. They received intradermal injection of botulinum toxin A in the residual limb area in contact with prosthetic socket. Abundance of sweating and degree of functional discomfort associated with it were assessed before, after 3 weeks, 6 and 12 months.

Results: Seventeen male patients, followed for post-traumatic limb amputation were included in the study. Discomfort and bothersome in relation to Hyperhidrosis did decrease after treatment (p<0,001). Reported satisfaction after 3 weeks was 73,33%. Improvement of prothesis loosening up after 3 weeks was 72,5% [±15,6]. Mean injection-induced pain on the visual analogue scale was 5.17/10 (±1.58). The mean interval after the onset of improvement was 5.13 days [min:3, max:8]. The mean time of improvement was 10.4 months after the injection [min:6, max:12]. No major adverse events were reported following treatment.

Conclusions: Intradermal injections of botulinum toxin in the symptomatic treatment of stump hyperhidrosis are effective and have few adverse effects. It improves the quality of life of our patients thanks to a better tolerance of the prosthesis.


War amputees, Hyperhidrosis, stump amputation



  1. Predictors of quality of life among individuals who have a lower limb amputation. Prosthet Orthot Int. 2008 June;32(2):p 231-43.
  2. Hagberg K, Brånemark R. Consequences of non-vascular trans-femoral amputation: A survey of quality of life, prosthetic use and problems. Prosthet Orthot Int. 2001 Dec;25(3):186–94.
  3. Bechara FG, Sand M, Hoffmann K, Boorboor P, Altmeyer P, Stuecker M. Histological and Clinical Findings in Different Surgical Strategies for Focal Axillary Hyperhidrosis. Dermatol Surg. 2008 Apr 22;34(8):1001–9.
  4. Hoorens I, Ongenae K. Primary focal hyperhidrosis: current treatment options and a step-by-step approach: Primary focal hyperhidrosis. J Eur Acad Dermatol Venereol. 2012 Jan;26(1):1–8.
  5. Maillard H, Lecouflet M. Prise en charge d’une hyperhidrose. Ann Dermatol Vénéréologie. 2015 Apr;142(4):252–61.
  6. Bushara KO, Park DM, Jones JC, Schutta HS. Botulinum toxin-a possible new treatment for axillary hyperhidrosis. Clin Exp Dermatol. 1996 Jul;21(4):276–8.
  7. Wollina, Helga Konrad, Tim Graefe, U. Botulinum Toxin A for Focal Hyperhidrosis in Leg Amputees: A Case Report. Acta Derm Venereol. 2000 Aug 7;80(3):226–7.
  8. Gratrix M, Hivnor C. Botulinum Toxin A Treatment for Hyperhidrosis in Patients With Prosthetic Limbs. Arch Dermatol. 2010;146(11):1314-5.
  9. García-Morales I, Pérez-Bernal A, Camacho F. Letter: Stump Hyperhidrosis in a Leg Amputee: Treatment with Botulinum Toxin A. Dermatol Surg. 2007 Nov;33(11):1401–2.
  10. Kern U, Kohl M, Seifert U, Schlereth T. Botulinum Toxin Type B in the Treatment of Residual Limb Hyperhidrosis for Lower Limb Amputees: A Pilot Study. Am J Phys Med Rehabil. 2011 Apr;90(4):321–9.
  11. Charrow A, DiFazio M, Foster L, Pasquina PF, Tsao JW. Intradermal Botulinum Toxin Type A Injection Effectively Reduces Residual Limb Hyperhidrosis in Amputees: A Case Series. Arch Phys Med Rehabil. 2008 Jul;89(7):1407–9.
  12. Pasquina PF, Perry BN, Alphonso AL, Finn S, Fitzpatrick KF, Tsao JW. Residual Limb Hyperhidrosis and RimabotulinumtoxinB: A Randomized Placebo-Controlled Study. Arch Phys Med Rehabil. 2016 May;97(5):659-664.e2.
  13. García-Morales I, Pérez-Bernal A, Camacho F. Letter: Stump Hyperhidrosis in a Leg Amputee: Treatment with Botulinum Toxin A. Dermatol Surg. 2007 Nov;33(11):1401–2.
  14. Hansen C, Godfrey B, Wixom J, McFadden M. Incidence, severity, and impact of hyperhidrosis in people with lower-limb amputation. J Rehabil Res Dev. 2015;52(1):31–40.
  15. Bisseriex H, Thefenne L, Compere S, Rogez D, Dochez F, Mercier H, and al. Le traitement de l’hyperhidrose du membre résiduel après amputation, apport de la toxine botulinique: à propos d’une série de cas à l’hôpital d’instruction des armées Percy. Ann Phys Rehabil Med. 2012 Oct;55:e84.
  16. Solish N, Bertucci V, Dansereau A, Hong HCH, Lynde C, Lupin M, et al. A Comprehensive Approach to the Recognition, Diagnosis, and Severity-Based Treatment of Focal Hyperhidrosis: Recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007 Aug;33(8):908–23.
  17. Hansen CR, Godfrey B. Residual Limb Hyperhidrosis Managed by Botulinum Toxin Injections, Enhanced by the Iodine-Starch Test: A Case Report. PM&R. 2017 Apr;9(4):415–8.
  18. Berthin C, Maillard H. Duration of Efficacy Increases with the Repetition of Botulinum Toxin A Injections in Primary Axillary Hyperhidrosis: A 15-year Study in 117 Patients. Acta Derm Venereol. 2019;99(13):1237–40.
  19. Kern U, Martin C, Scheicher S, Müller H. Does botulinum toxin a make prosthesis use easier for amputees? J Rehabil Med. 2004 Sep 1;36(5):238–9.
  20. Compère S, Bisseriex H, Truffaut S, Thefenne L, Lapeyre E. Apport des techniques de mésothérapie dans le traitement de l’hyperhidrose des membres résiduels par toxine botulique : étude d’un cas. Ann Phys Rehabil Med. 2013 Oct;56:e22–3.
  21. Kern U, Martin C, Scheicher S, Müller H. Effects of Botulinum Toxin Type B on Stump Pain and Involuntary Movements of the Stump: Am J Phys Med Rehabil. 2004 May;83(5):396–9.
  22. Wu CJ, Chang CK, Wang CY, Liao YS, Chen SG. Efficacy and Safety of Botulinum Toxin A in Axillary Bromhidrosis and Associated Histological Changes in Sweat Glands: A Prospective Randomized Double-Blind Side-by-Side Comparison Clinical Study. Dermatol Surg. 2019 Dec;45(12):1605–9.
  23. Rouientan A, Alizadeh Otaghvar H, Mahmoudvand H, and al. Rare Complication of Botox Injection: A Case Report. WORLD J Plast Surg. 2019 Jan 1;8(1):116–9.
  24. Skiveren J, Larsen H, Kjaerby E, Larsen R. The Influence of Needle Size on Pain Perception in Patients Treated with Botulinum Toxin A Injections for Axillary Hyperhidrosis. Acta Derm Venereol. 2011;91(1):72–4.