When topical therapy and tap water iontophoresis (TWI) fail, are unavailable, or are deemed unsatisfactory by patients with palmar or plantar hyperhidrosis (HH), the next logical treatment option is botulinum toxin type A (BTX-A). Skill and precision are required to treat palmar and plantar HH because of the dense innervation in the palms and soles. This article describes best practice techniques for BTX-A (Botox), including suggested dilution and syringe selection, injection technique, dose and injection grids, and anesthesia recommendations. In addition, general BTX-A background and special considerations for treating palmar and plantar HH are provided. Insurance reimbursement for treating HH with BTX-A can be challenging; navigating the insurance reimbursement process will be discussed.