BACKGROUND Peristomal hyperhidrosis can interfere with pouch adherence, resulting in pouch leakage and peristomal skin damage. CASE A patient with autonomic dysregulation resulting in excessive sweating (hyperhidrosis) experienced difficulty with adherence of her ileostomy appliance. Two hundred units of botulinum toxin A (BTX-A) were injected in the dermis of the surrounding skin in order to improve adherence of her pouching system and alleviate moisture of her peristomal skin. RESULTS Following BTX-A injection, the typical wear time of her pouching system improved from less than 24 hours to 120 hours. Peristomal moisture-associated skin damage resolved almost completely. These effects lasted 3 months. A repeat intradermal BTX-A injection had a similar positive effect. CONCLUSION Peristomal hyperhidrosis can be controlled with BTX-A intradermal injections, improving patient pouch adherence and alleviating moisture-associated skin damage.