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Future Drugs Expert Review of Dermatology: Hyperhidrosis: A Comprehensive and Practical Approach to Patient Management
Introduction
Approximately 60 healthcare professionals and related industry leaders (including representatives from over-the-counter antiperspirant manufacturers, as well as pharmaceutical companies) gathered in Las Vegas (NV, USA) on October 14, 2006, for an all-day symposium titled 'Hyperhidrosis: A Comprehensive and Practical Approach to Patient Management’. The symposium was organized and administered by the nonprofit International Hyperhidrosis Society, which brought together leaders in the hyperhidrosis field from a variety of medical specialties to discuss the problem of excessive sweating, the latest treatment options and practical tips for the healthcare provider’s practice.
It is estimated that 3% of the US population, or nearly 7.8 million Americans, suffer from hyperhidrosis. It is defined as sweating that is more than is required to maintain normal thermal regulation and may present as generalized sweating or as focal sweating [1]. Generalized sweating may often be caused by an underlying medical condition or as a side effect of a medication, whereas primary focal hyperhidrosis is a medical condition unto itself. This symposia touched briefly upon the need for healthcare providers to investigate and treat underlying medical conditions that may cause undue sweating or to adjust medications appropriately to relieve sweating that is a side effect. However it mainly focused on the diagnosis, treatment and patient and practice management of primary focal hyperhidrosis.
The symposia: Hyperhidrosis
Early in the program, an important overview of the prevalence and negative psychosocial effects of hyperhidrosis was provided; this explained why the condition demands effective treatment. According to the results of a self-administered questionnaire, called the dermatology life quality index, hyperhidrosis of the palms and/or of the axillae was ranked by patients as having more negative impact on quality of life than the more commonly discussed conditions of psoriasis, atopic dermatitis, acne, rosacea and basal cell carcinoma [2]. Another rating scale, called the illness intrusiveness rating scale, administered to active contributors to an internet-based hyperhidrosis discussion group, showed that responders felt that hyperhidrosis intruded upon their lives (they were asked about 13 domains, including health, work, recreation, sex life, family relations, self-expression and civic involvement) more significantly than end-stage renal disease and rheumatoid arthritis [3]. In a hyperhidrosis-specific questionnaire of 48 patients with hyperhidrosis, patients indicated that they were impaired in many ways, such as choice of occupation, social interactions, shaking hands, intimate touching and dancing. Patients also indicated that they felt more disgust towards themselves than they felt was true for others [4].
Recognizing the prevalence and impact of hyperhidrosis, the panel of presenters went on to focus on how these patients can be best cared for and gave detailed presentations about each of the available treatment options: topical antiperspirant products, systemic medications, iontophoresis, botulinum toxin type A injections, local surgeries to remove sweat glands in the axillae and endoscopic thoracic sympathectomy to sever the nerve pathways to the hands and/or axillae that control sweating. Video and live demonstrations of iontophoresis (which involves running an electric current through water to treat hyperhidrosis of the palms or feet) and of botulinum toxin type A injections to treat hyperhidrosis of the axillae and of the hands were provided. In 2004, the US FDA approved botulinum toxin type A (sold in the USA under the brand name Botox®, manufactured by Allergan Inc., CA, USA) for the treatment of primary focal axillary hyperhidrosis that has not responded to topical antiperspirant therapy. Physicians using botulinum toxin type A injections to treat excessive sweating of the hands, feet and head/face are doing so 'off-label’.
"While nonprescription topical antiperspirants are often considered the first-line of treatment for hyperhidrosis," said Dee Anna Glaser (St Louis University School of Medicine, MO, USA), "they are useful to a limited number of individuals with 87% of patients with axillary hyperhidrosis in a recent study rating their over-the-counter antiperspirants as ineffective". Prescription strength antiperspirants with the active ingredient aluminum chloride can provide some relief from excessive sweating symptoms but are poorly tolerated clinically owing to stinging, irritation and other local side effects. Palmar hyperhidrosis is less responsive to aluminum chloride therapy and successful treatment may require concentrations up to 30% [5].
"Systemic medications may also be used to treat hyperhidrosis", said D Glaser but no systemic agents have been tested as hyperhidrosis treatment through clinical trials and no systemic agents are approved by the FDA for the treatment of hyperhidrosis. Side effects, such as dry mouth, associated with systemic anticholinergics (the most commonly used agents for the oral treatment of sweating) limit their long-term usefulness. Anticholinergics and other systemic medications may, however, be used to treat hyperhidrosis short-term to provide the patient with temporary relief from problem sweating for special events (where a patient may feel that he/she must make a good impression or look his/her best) or for anxiety-inducing events, such as workplace presentations or job interviews.
Iontophoresis
A promising and long-used treatment for hyperhidrosis of the hands and feet is iontophoresis. Iontophoresis is defined as the passing of an ionized substance through intact skin by the application of a direct electrical current [6]. A 1952 observational study in 113 patients reported a 91% response rate in palmoplantar hyperhidrosis [7]. A more recent study of 11 patients found an 81% reduction in sweat production with improvement maintained with treatment provided every other week [8]. Many papers have delineated the role of using tap water alone for ionotophoresis therapy of hyperhidrosis. Lewis Stolman (University of Medicine and Dentistry of New Jersey-New Jersey Medical School, NJ, USA) reviewed the use of this therapy and discussed the role of adding anticholinergic drugs to the tap water to improve the efficacy and the duration of the benefit when required. Although highly effective, one of the major limitations of this treatment is the time commitment, especially early in the course.
Botulinum toxin type A
In 2004, the FDA approved botulinum toxin type A for the treatment of axillary hyperhidrosis. Botox treatment is very effective. One clinical study involved 322 patients with severe underarm sweating. Highlights of this multicentered North American trial were summarized:
• A total of 75% of Botox treated patients achieved an effective response compared with only 25% of subjects treated with placebo;
• Over 80% of Botox treated patients achieved a greater than 75% reduction in sweating compared with only 21% of the patients treated with placebo;
• Treatment satisfaction was high in the study with 85% of treated subjects rating the Botox treatment as more satisfying than previously tried therapies.
Treatment of the axilla is well tolerated and a straight forward office-based procedure to perform. No anesthesia or anesthetics are required, however, when treating nonaxillary sites of the body, pain control can be an issue. Of particular interest at the hyperhidrosis meeting was a discussion of pain-relieving techniques for use during the injection procedure of botulinum toxin type A for palmar or plantar hyperhidrosis. While nerve blocks were often used for this purpose, a number of presenters indicated that they now favor the use of ice for pain control during the procedure. Either alone or with the help of an assistant, those injecting botulinum toxin type A may use an ice cube to temporarily numb each injection site before the injection is given. The combination of the cold and the pressure afforded by the ice provides ample anesthesia for many patients. A live demonstration of this technique was provided as the group gathered in small groups to observe the technique and ask questions about it. Two hyperhidrosis patients from the Las Vegas area had volunteered to receive botulinum toxin type A injections for underarm sweating and one also received injections for palmar sweating. In a similar vein, attendees were able to do a hands-on test of the RA Fischer iontophoresis device and to feel the electric current used for treatment by placing their hands in the pans of water. Attendees demonstrated varied degrees of tolerance for the discomfort caused by iontophoresis – demonstrating the need for flexibility in determining who is a good candidate for iontophoresis and for understanding potential patient discomfort during the procedure.
Discussion
During a lively question-and-answer session attendees asked questions about the treatment of facial, head and neck sweating and local surgical techniques for axillary hyperhidrosis, such as liposuction and curettage. Additionally, Samuel Ahn (David Geffen School of Medicine at UCLA, CA, USA), provided a thorough review of his procedure for screening patients for the invasive endoscopic thoracic sympathectomy surgical treatment for axillary and/or palmar hyperhidrosis. He demonstrated the surgery via a video and stressed the imperative role of informing the patient of the very real risks (including severe compensatory sweating) associated with the delicate surgery. In addition to informing the patient of all of the potential risks, he urged surgeons to provide potential patients with adequate time to process that information before having them sign an 'informed consent’ document.
Concluding the day was a discussion of how to use physician extenders (registered nurses, physician assistants and other trained medical staff) to help build and manage a hyperhidrosis practice. With adequate training, nurses and other staff can help provide patients with iontophoresis and provide information over the telephone regarding treatment options and their appropriate use. Physician assistants may even be trained to provide botulinum toxin injections. For US-based attendees there was also a practical discussion of health insurance reimbursement for hyperhidrosis treatment. The full-day session was accredited by the American Academy of Dermatology (AAD) and attendees received a certificate for 6 hours of AAD category 1 CME credit along with resources, including the complete slide presentation and lists of medical conditions and medications that may cause secondary, generalized hyperhidrosis. The International Hyperhidrosis Society will host multiple similar and updated sessions in 2007. Visit www.sweathelp.org for more information. Similarily to the October 14, 2006, session, each International Hyperhidrosis Society program is led by a panel of expert physicians with experience of treating hyperhidrosis by a variety of methods.
Conclusions
Hyperhidrosis, or excessive sweating, is a serious medical condition affecting approximately 3% of the population. While often under-reported, primary focal hyperhidrosis of the hands, feet or underarms has significant negative effects on patients’ quality of life. The recent International Hyperhidrosis Society continuing medical education event, titled 'Hyperhidrosis: A Comprehensive and Practical Approach to Patient Management’, provided insights from leaders in the field of hyperhidrosis research and treatment on how to manage the condition using topical therapies, iontophoresis, botulinum toxin type A injections and, in selected patients, systemic agents, local surgical techniques or endoscopic thoracic sympathectomy. Future sessions will continue to provide the most recent data on the condition, its effects and treatments. As more patients and physicians begin to recognize that excessive sweating is a treatable medical condition, the demand for effective treatment to help mitigate the potentially severe effects of hyperhidrosis on a patients’ quality of life and self-esteem will become more imperative. Medical professionals, and particularly dermatologists, who choose to treat hyperhidrosis based on the latest research in various treatments’ uses and effectiveness have the power to greatly improve patients’ lives. According to one of the symposia’s panelists, treating hyperhidrosis patients is the most meaningful and satisfying part of his practice because of the dramatic positive changes it makes to his patients’ lives.
Conflict of interests
Dee Anna Glaser is an investigator for and consultant to Allergan, Inc.
References
1 Hornberger J, Grimes K, Naumann M et al. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J. Am. Acad. Dermatol. 51, 274–286 (2004).
2 Finlay AY, Khan GK. Dermatology life quality index (DLQI) – a simple practical measure for routine clinical use. Clin. Exp. Derm. 19, 210–216 (1994).
3 Cina CS, Clase CM. The Illness Intrusiveness Rating Scale: a measure of severity in individuals with hyperhidrosis. Qual. Life Res. 8, 693–698 (1999).
4 Amir M, Arish A, Weinstein Y et al. Impairment in quality of life among patients seeking surgery for hyperhidrosis (excessive sweating): preliminary results. Isr. J. Psychiatry Relat. Sci. 37, 25–31 (2000).
5 Tögel B, Greve B, Raulin, C. Current therapeutic strategies for hyperhidrosis: a review. Eur. J. Dermatol. 12, 219–223 (2002).
6 Stolman LP. Treatment of hyperhidrosis. Dermatol. Clin. 16, 863–869 (1998).
7 Bouman H, Lentzer EM. The treatment of hyperhidrosis of hands and feet with constant current. Am. J. Phys. Med. 31, 158–169 (1952).
8 Dahl C, Glent-Madsen L. Treatment of hyperhidrosis manuum by tap water iontophoresis. Acta. Derm. Venereol. 69, 346–348 (1989).
Affiliations
Dee Anna Glaser
Professor, Vice Chairman, Saint Louis University, Department of Dermatology, School of Medicine, St. Louis, MO, USA.
Angela Ballard
Editor, International Hyperhidrosis Society, Philadelphia, PA 19106 USA.
http://www.future-drugs.com/doi/pdf/10.1586/17469872.1.6.773
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