1) The document describes a case of a 47-year-old man who developed gustatory sweating (Frey's syndrome) after undergoing endoscopic thoracic sympathectomy surgery 16 years prior. 2) Frey's syndrome causes sweating, flushing, and warming of the face and neck in response to eating. It is treated using botulinum toxin injections, which were effective in resolving the patient's symptoms. 3) Botulinum toxin injections of 3 mouse units per square centimeter is an effective, minimally invasive treatment for Frey's syndrome that can provide relief of symptoms for over 12 months.

1. S K I N / D E R M AT O L O G Y
31Aesthetic Medicine • April 2016
CASE FILESwww.aestheticmed.co.uk
Dr Patrick Treacy shares some of his most challenging cases. This month he talks
about treating post endoscopic thoracic sympathectomy “gustatory sweating” with
botulinum toxin A
Dr Treacy’s
CASEBOOK
A
47-year-old English patient presented with
redness and sweating on the forehead and
temporal area and in the lateral neck and
décolletage area bilaterally. The symptoms
appeared whenever he ate, saw or thought about
certain foods, especially spicy foods such as chorizo. He
also had mild discharge from the nose when smelling certain
food. The symptoms started after the patient underwent
an endoscopic thoracic sympathectomy 16 years before.
This is a surgical procedure wherein part of the sympathetic
trunk is cut or clamped to treat sweating of the hands or
blushing. As a result of severance and inappropriate
regeneration, the parasympathetic nerve fibres may switch
course, resulting in “gustatory sweating” or sweating in
the anticipation of eating, instead of the normal
salivatoryresponse.
Frey’s syndrome is a rare disorder, the
symptoms of which include sweating,
flushing and warming over the
frontalis, preauricular, temporal
areas and neck area following a
gustatory stimulus. It often occurs
in patients who have undergone
parotidectomy, submandibular
gland surgery, radical neck
dissection or endoscopic thoracic
sympathectomy. It is caused by the
aberrant regrowth of facial autonomic
nerve fibres.
TREATMENT
Currently there are several options used to treat patients
withFrey’ssyndrome;forexample,thetopicalapplicationof
anticholinergics and anti-perspirants, and the intradermal
injection of botulinum toxin. The options include:
Topical anti-perspirant (20% aluminum chloride solution)
Application of an ointment containing an anti-cholinergic
drug such as 3% scopolamine, 2% glycopyrolate or
diphemanil methylsulphate
Topicalapplicationofanadrenoceptoragonist(clonidine)
Blockage of parasympathetic outflow by way of alcohol
injection or 2% lignocaine injections at various sites such
as the otic ganglion the auriculotemporal nerve
Botox (patients who are unresponsive to topical therapy
may want to consider a trial of botox before
considering surgical options)
Many publications say it is uncertain which
treatment is most effective and safe.1
However, the author like many other
physicians has found that Botox A
injection is a safe and effective
treatment with long-lasting
effects for patients with extensive
gustatory sweating.2,3
DIAGNOSIS
Diagnosis is made based on clinical
signs and symptoms and a test,
called the Minor Iodine-Starch test. The
affected area of the face is painted with
iodine which is allowed to dry, then dry corn
starch is applied to the face. The starch turns blue on
exposure to iodine in the presence of sweat.4
METHOD
Injection dosage of 3 MU/cm2 of botulinum toxin A into
the areas testing positive as a result of the Minor Iodine-
Starch test.
CONCLUSION
Frey’s syndrome or gustatory sweating was first described
by Baillarger in 1853. Lucie Frey had described a patient
as “auriculotemporal syndrome” in 1923. The explanation
Frey’s syndrome is a rare
disorder, the symptoms
of which include sweating,
flushing and warming over the
frontalis, preauricular, temporal
areas and neck area following
a gustatory stimulus

2. 32 Aesthetic Medicine • April 2016
CASE FILES www.aestheticmed.co.uk
S K I N / D E R M AT O L O G Y
Please advise on captions
Dr Patrick Treacy is CEO Ailesbury Clinics, chairman of the Irish Association of Cosmetic Doctors and
Irish regional representative of the British College of Aesthetic Medicine (BCAM). He is also president of
the World Trichology Association. Dr Treacy has won a number of awards for his contributions to facial
aesthetics and hair transplants including the AMEC Award in Paris in 2014. Dr Treacy also sits on the
editorial boards of three international journals and features regularly on international television and radio
programmes. He is on the scientific committee for AMWC Monaco 2015, AMWC Eastern Europe 2015,
AMWC Latin America 2015, RSM ICG7 (London) and Faculty IMCAS Paris 2015 and IMCAS China 2015.
REFERENCES
1. Cochrane Database Syst Rev. 2015 Mar 17;3:CD009959. doi: 10.1002/14651858.
CD009959.pub2. Interventions for the treatment of Frey’s syndrome. Li C1, Wu
F, Zhang Q, Gao Q, Shi Z, Li L.
2. Mund Kiefer Gesichtschir. 2004 Nov;8(6):369-75. Epub 2004 Oct 29.
[Botulinum toxin for treatment of gustatory sweating. A prospective
randomized study].
3. Head Neck. 2003 Aug;25(8):624-8. Treatment of gustatory sweating (Frey’s
syndrome) with botulinum toxin A. Eckardt A1, Kuettner C.
4. Choi, Hyo Geun; Kwon, Sae Young; Won, Jung Youn; Yoo, Seung Woo; Lee, Min
Gu; Kim, Si Whan; Park, Bumjung (2013). “Comparisons of Three Indicators
for Frey’s Syndrome: Subjective Symptoms, Minor’s Starch Iodine Test, and
Infrared Thermography”. Clinical and Experimental Otorhinolaryngology 6
(4): 249. doi:10.3342/ceo.2013.6.4.249. ISSN 1976-8710. Ann Vasc Surg. 2013
May;27(4):447-53. doi: 10.1016/j.avsg.2012.05.026. Epub 2013 Feb 11.
5. Clin Auton Res. 2008 Apr;18(2):80-3. doi: 10.1007/s10286-008-0460-5.
Results, side effects and complications after thoracoscopic sympathetic block
by clamping. The monza clinical experience. Sciuchetti JF1, Corti F, Ballabio D,
Angeli MC.
6. Technical difficulties and complications of sympathectomy in the treatment
of hyperhidrosis: an analysis of 1731 cases. de Andrade Filho LO1, Kuzniec S,
Wolosker N, Yazbek G, Kauffman P, Milanez de Campos JR.
7. J Med Assoc Thai. 2007 Nov;90(11):2397-402. Treatment of Frey’s syndrome
with botulinum toxin. Pomprasit M1, Chintrakarn C.
for this symptom has been an aberrant regeneration of
cholinergic parasympathetic fibres, which regenerate
and anastomosis with postganglionic sympathetic
fibres that supply vessels and sweat glands of the skin.
However, the symptom is being seen more commonly post
endoscopic thoracic sympathectomy used for blushing or
hyperhidrosis.5
This has led to a modified technique using
endoclips where major complications are compensatory
sweating (22%) Horner’s syndrome (1%) pneumothorax
(3%) and no cases of gustatory sweating were reported.6
This patient had a complete resolution and confirms
intracutaneous injection of botulinum toxin A represents
a highly effective and minimally invasive procedure for the
treatment of Frey’s syndrome. Studies show that a dosage
of 3 MU/cm2 of botulinum toxin A achieves a complete and
reliable blockade of gustatory sweating lasting for at least
12 months.7
AM
Proposed mechanism of Frey syndrome.
Treatment Algorithm for Frey’s Syndrome
Gustatory Hyperhidrosis
(Frey’s Syndrome)
Topical anti-perspirant
therapy )aluminum
chloride hexahydrate)
Pay special attention
to correct application
time/technique and
education re. avoiding
side effects.
Good response:
repeat p.r.n.
No response
or patient
requests
botullinum toxin A injections
Consider systemic meds:
1. Anticholinergics
(propantheline, oxybutynin,
glycopyrronium, benztropine)
2. Benzodiazepines
(short course, as needed)
3. Diltiazem
4. Clonidine
5.Others
No response
or patient
requests