Therapies for hyperhidrosis

January 19, 2009

Kohala Coast, HI - The definition of hyperhidrosis is to have sweating beyond what is needed for normal physiologic function, which is about four to five times more than what is normal, said David M. Pariser, M.D., F.A.C.P., at the Winter Clinical Dermatology Conference.

Kohala Coast, HI

- The definition of hyperhidrosis is to have sweating beyond what is needed for normal physiologic function, which is about four to five times more than what is normal, said David M. Pariser, M.D., F.A.C.P., at the Winter Clinical Dermatology Conference.

Treatment options for hyperhidrosis range from noninvasive to surgical, Dr. Pariser said, the noninvasive options being topical antiperspirants and other topical agents, iontophoresis and systemic medications.

A new generation of over-the-counter antiperspirants provide a significant benefit with low irritation, Dr. Pariser said. These products contain aluminum zirconium tricholorohydrex and usually have the word "clinical" in them.

The new antiperspirants are best applied overnight, when the least amount of sweating occurs. It’s best to apply the product to dry skin to avoid irritation and acid formation and to wash in the morning before sweating begins, according to Dr. Pariser.

These products work by forming a superficial plug that reduces the flow of perspiration, Dr. Pariser said. In addition, he said they are widely used, inexpensive, nontoxic, irritating and work better on axillae than palms or soles.

For palmar and plantar hyperhidrosis, Dr. Pariser recommends iontophoresis, which "passes an ionized substance through intact skin by the use of direct electrical current."

Though the method is effective, Dr. Pariser said, the mechanism of action is not fully explained. Some theories suggest that the method plugs sweat glands from ion deposition, blocks sympathetic nerve transmission or possibly decreases in pH due to accumulation of hydrogen ions.

"Many insurance companies consider treatment of hyperhidrosis with iontophoresis medically necessary when topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash,"Dr. Pariser said.

Systemic medications are another noninvasive option. However, no systemic agents have been tested in clinical trials, and there are no systemic agents approved by the FDA for hyperhidrosis, he said.

Even so, anticholinergics can be used, including propanteheline, glycopyrronium bromide and benztropine, but these can cause a large list of side effects. Dr. Pariser said that his preferred systemic medication is Glycopyrrolate (Robinul).

Botulinum toxin (Botox, Allergan) injections for axillary hyperhidrosis are approved in the U.S., U.K, and Canada, but they can also be used to treat palmar and plantar hyperhidrosis, Dr. Pariser said.

"Localized intradermal injections of botulinum toxin type A markedly reduce sweating by blocking the release of acetylcholine from nerve fibers that stimulate eccrine glands," Dr. Pariser said.

The treatment is highly effective with long duration and significantly improves the patient’s quality of life, he added.

The most invasive option to treat hyperhidrosis is endoscopic thoracic sympathectomy (ETS), which is a surgery reserved for patients with very severe symptoms who have not responded to other treatments.

The surgery is very effective for palmar sweating but less effective for axillary sweating, he said, and it is associated with complications that cause ETS to be an unacceptable treatment for most patients.

In general, treatment of patients with hyperhidrosis is easily learned, can be easily integrated into routine practice, can be performed by physician assistants, is economically viable and significantly improves the quality of life of the patient, according to Dr. Pariser.

"Treating hyperhidrosis leads to greater improvement of a patient’s quality of life than treatment of any other dermatologic disorder," he said. DT