Hyperhidrosis: The Patient

1
Hyperhidrosis The Patients Perspective

• "I can't buy nice clothes, because I have to
  throw them away after wearing them once or twice,
  especially white things. I probably spend 2
  hours a day dealing with sweating wiping,
  refreshening, showering, washing clothes but I
  really spend more time than that because I never
  stop thinking about it. When I go to a club with
  my friends, the first thing I do is check out the
  bathroom. Are there plenty of paper towels for me
  to stuff in my armpits? Is there an air-dryer I
  can use to dry my armpits? I never gesture with
  my hands people would see the sweat stains that
  go halfway down my arms, or, even worse, the
  paper towels might fall out. When I visit friends
  or relatives, I hug everyone before I take off my
  coat."
•  
• Lisa, 26-year-old hyperhidrosis patient

2
Hyperhidrosis

• Hyperhidrosis is defined as excessive sweating
• Qualitative definition is subjective
• Quantitative definition for research is
  production of more than 100 mg of sweat in 1
  axilla over 5 minutes
• Hyperhidrosis can be disabling in private and
  professional life
• Cutaneous effects include dehydration,
  maceration, and secondary infections

3
Types of Hyperhidrosis

• Focal hyperhidrosis
• Most often essential (idiopathic)
• Cause is unknown sweat glands show no histologic
  abnormalities
• Usually affects palms/soles (60 of pts), axillae
  (30-40), or face (10)
• Affects up to 0.5 of population
• Positive family history in 30-50 of cases
  suggests genetic component
• Generalized hyperhidrosis
• Excessive sweating over entire body
• Causes include diabetes, chronic infectious
  diseases, malignancy

4
Psychiatric Aspects of Hyperhidrosis

• Hyperhidrosis can be secondary to social anxiety
  disorder (SAD)
• In 1 study,1 endoscopic thoracic sympathectomy
  significantly relieved hyperhidrosis and other
  symptoms such as blushing and trembling hands in
  SAD patients
• Other treatments explored in SAD patients2
• Selective serotonin reuptake inhibitors (53
  reduction in sweating)
• GABAergic anticonvulsant (40 reduction)
• Cognitive behavior therapy (25 reduction)

1Telaranta T. Eur J Surg. 199858027-32.
2Davidson JR, et al . Submitted.
5
Hyperhidrosis Treatments

• Antiperspirants and deodorants
• Iontophoresis
• Anticholinergic drugs
• Local surgical excision
• Endoscopic thoracic sympathectomy
• Botulinum toxin A

6
Antiperspirants and Deodorants

• Antiperspirant
• Astringent that decreases eccrine and apocrine
  sweat secretion
• Deodorant
• Topical agent that masks and removes odor from
  the axillae
• Prescription antiperspirants containing 20 or
  6.25 aluminum chloride in anhydrous ethyl
  alcohol solution are effective for many patients

7
Iontophoresis

• Topical introduction of ionized medication into
  skin with direct current
• Generally used to treat palmar/plantar
  hyperhidrosis
• Tap water generally used anticholinergic agents
  sometimes added
• May plug sweat ducts or induce electrical charge
  in sweat gland that disrupts sweat secretion
• Simple galvanic device has been shown to relieve
  symptoms in 85 of patients1
• Side effects include dry, cracked, fissured skin
  in treated area

1Levit F. Arch Dermatol. 196898505-507. Levit
F. Cutis. 198026192-194.
8
Anticholinergic Drugs

• Glycopyrrolate, atropine, propantheline bromide,
  oxybutynin have been used
• Success is variable
• Side effects include dry mouth, urinary
  retention, constipation, palpitations, and
  failure of ocular accommodation

9
Local Surgical Management

• Approaches include
• En bloc excision of sweating area
• Partial resection of axillary skin and
  subcutaneous tissue
• Cryosurgery
• Suction curettage
• Limited information on long-term outcome and
  patient satisfaction
• Side effects include bleeding, hematomas, scars,
  infection

10
Endoscopic Thoracic Sympathectomy (ETS)

• ETS has superseded conventional open surgery
• Minimally invasive video-assisted surgical
  techniques have increased acceptance
• Usual technique is to destroy thoracic
  sympathetic ganglia T2 and T3 by electrocautery
  (palmar hyperhidrosis)
• T4 also destroyed in treatment of axillary
  hyperhidrosis

11
ETS Efficacy and Complications

• Approximately 98 of patients treated for palmar
  hyperhidrosis achieve immediate, complete
  anhidrosis1
• In axillary hyperhidrosis, 83 of treated
  patients had dry skin postoperatively 68 had
  dry skin at long-term followup2
• 72 of patients treated for palmar hyperhidrosis
  were satisfied with ETS at long-term follow-up
• 37 of patients treated for axillary
  hyperhidrosis were satisfied with ETS at
  long-term follow-up
• Rare complications include pneumothorax, Horner's
  syndrome, chronic pain
• Compensatory sweating is a frequent complication
  and primary reason for patient dissatisfaction.

1Herbst F, et al. Ann Surg. 199422086-90.
2Zacherl J, et al. Eur J Surg. 199843-46.
12
ETS Clinical Trial Results
Zacherl J, et al. Eur J Surg. 199843-46.
13
Botulinum Toxin A (BTX-A)

• Novel, minimally invasive treatment
• Temporarily blocks release of acetylcholine from
  cholinergic sudomotor fibers
• Injected intradermally into hyperhidrotic areas

14
BTX-A in Axillary HyperhidrosisClinical Trial
Objective and Design

• Objective
• Evaluate the safety and efficacy of BTX-A in
  treatment of bilateral axillary hyperhidrosis
• Design
• Randomized, parallel-group, double-blind,
  placebo-controlled trial
• Patients
• 307 patients aged 17-75 years with bilateral
  axillary hyperhidrosis severe enough to interfere
  with daily life
• Treatment Regimen
• Patients received either a single treatment of
  BTX-A 50 U per axilla or 10-15 intradermal
  injections of placebo per axilla
• Follow-up assessments were conducted at 1, 4, 8,
  12, and 16 weeks post-treatment

Naumann M, et al. BMJ. 2001323596-599.
15
BTX-A in Axillary HyperhidrosisClinical Trial
Results

• At Week 4, 93.8 of patients treated with BTX-A
  were classified as responders (gt50 reduction in
  sweat production) vs 35.9 of the placebo-treated
  group
• At Week 4, mean percentage reduction in sweat was
  83.5 in the BTX-A-treated group vs 20.8 in the
  placebo-treated group
• 207 patients were followed for 12 more months
• Mean duration of benefit from a single BTX-A
  treatment was 7 months

Naumann M, et al. BMJ. 2001323596-599.
16
BTX-A Clinical Trial Results at 4 Weeks


P lt 0.001 vs placebo. Naumann M, et al. BMJ.
2001323596-599.