Contemporary Algorithm for Treating Bromhidrosis: A Review of Treatment Available

Bromhidrosis significantly impacts individuals' social, professional, and emotional well-being. Traditional treatments such as en bloc excision and alcohol injections are now less favored due to associated complications and suboptimal outcomes. Current evidence identifies botulinum toxin A (BTX-A) as the first-line treatment for mild to moderate cases (Grade 0-2), attributed to its high efficacy, excellent safety profile, and minimally invasive nature. BTX-A achieves effectiveness rates exceeding 90%, with results persisting for 3-8 months. A standardized grading system guides treatment selection, reserving surgical interventions for severe cases (Grade 3) or situations where BTX-A is contraindicated. Modern surgical approaches, such as hydrosurgery and endoscopic-assisted procedures, have shown improved outcomes and significantly fewer complications compared to traditional methods. Energy-based therapies, including laser, radiofrequency, and microwave treatments, also provide viable alternatives for patients unsuitable for BTX-A, demonstrating documented efficacy and minimal invasiveness. This review proposes an evidence-based treatment algorithm for bromhidrosis management, highlighting the central role of BTX-A while detailing alternative strategies. The framework integrates disease severity assessment, patient preferences, and cost considerations to support optimal clinical decision-making. By adopting this systematic approach, clinicians can enhance treatment selection and improve patient outcomes.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00266 .