A realistic look at hyperhidrosis treatments

Dr. Cha

Consider this: An axillary hyperhidrosis patient reviewing her office-based treatment experience on RealSelf.com gave her treatment a Not Worth It rating. She wrote that she tried Botox (Allergan) and MiraDry (MiraDry) and those treatments worked, but she couldn’t afford treatment maintenance. So, she bought a less expensive over-the-counter option, Certain Dri (Clarion Brands). It works and is affordable, according to her review.

Understanding hyperhidrosis and focusing on what’s practical for patients who want the condition treated are themes of a comprehensive hyperhidrosis review published September 2019 in the Journal of the American Academy of Dermatology (JAAD).

“I found that recent papers focus on the new technology and expensive treatments that majority of our patients cannot afford,” according to review author Jisun Cha, M.D., associate professor of dermatology at Thomas Jefferson University. “This paper focuses on the practical points, for example how to use topical antiperspirants or how to use iontophoresis devices.”

Dr. Cha tells Dermatology Times that she has encountered many hyperhidrosis patients who were discouraged not only by the costs of treatments like botulinum toxin injection or laser therapies, but also because they couldn’t tolerate the pain of injection or simply were afraid of needles. And while patients might know about the more expensive hyperhidrosis treatment options, many are not well informed about the less expensive treatments or how to apply those treatments.

“I wanted to reiterate the basic and practical part of hyperhidrosis treatment that seems to be underestimated by both patients and providers,” Dr. Cha says.

The review addresses disease pathophysiology, diagnosis and treatment, as well as emotional and financial burdens associated with hyperhidrosis.

Hyperhidrosis Types & Diagnostic Pearls

Hyperhidrosis, which dermatologists diagnose when sweating exceeds thermoregulatory needs and causes significant emotional, physical or social issues, affects at least 4.8% of people in the U.S., according to the paper.

About 93% of patients have primary hyperhidrosis, in which they generally have focal and bilateral sweating impacting the axillae, palms, soles and craniofacial areas. The primary type often begins between 14 and 25 years of age and results from neurogenic overactivity, even though patients have normal eccrine sweat glands.

While many think complex autonomic nervous system dysfunction and aberrant central control of emotions are primary hyperhidrosis etiologies, genetics might come into play with primary hyperhidrosis, as 35% to 56% of these patients have a family history, according to the review.

Other patients have secondary hyperhidrosis, with a more generalized and asymmetric distribution resulting from an underlying cause, such as disease or medication. Antidepressants, antibiotics antivirals and hypoglycemic agents are among the drugs that can cause secondary generalized hyperhidrosis. Alcohol, cocaine and heroin use and withdrawal can cause the secondary type, too.

The secondary type often begins after age 25, lacks family history and often includes nighttime sweating.

“Secondary hyperhidrosis needs to be excluded before diagnosing primary hyperhidrosis,” the authors write.

Dermatologists who suspect primary hyperhidrosis do not need to order diagnostic tests, according got the paper. But sweat production tests can help determine sweating severity and help direct treatment, the authors write.

Hyperhidrosis & Quality of Life

Hyperhidrosis can significantly impact patients’ quality of life.

Researchers have reported the disorder impairs patients’ daily functions and social interactions. More than half of patients experience a moderate to severe emotional impact from hyperhidrosis. And these patients are more likely than people without the excessive sweating to be anxious or depressed, according to the review.

The authors cite research suggesting nearly one-third of patients with axillary hyperhidrosis say it is hardly bearable or intolerable and negatively affects them daily.

Hyperhidrosis Treatment Tips

Dr. Cha says her treatment preferences depend on the type of hyperhidrosis.

“For a localized axillary hyperhidrosis, I first check if the patient [has] tried topical antiperspirants properly because people are often not aware how to use the topical antiperspirant. They should be applying it at bedtime and leave it on for at least six hours before washing it away,” she says. “I have seen patients who… confused… topical antiperspirants with deodorants. Once the patients have tried topical antiperspirant at the maximum strength with proper method and duration and the problem is persistent, a botulinum toxin injection could be the next option.”

Topical treatment isn’t generally applicable for localized craniofacial hyperhidrosis. And this particular type of hyperhidrosis tends to be more related with various precipitating triggers, according to Dr. Cha.

“The patient may try to identify the trigger and avoid it when they anticipate it’s coming. Simultaneously we can treat the area like a scalp with botulinum toxin injection, or we may consider starting the systemic anticholinergics from the early stage of the treatment,” she says. “For a palmoplantar hyperhidrosis, a topical antiperspirant or iontophoresis would be my preferred choice. We can also consider the botulinum toxin injection but it is very painful and the efficacy is not consistent as in the axillary hyperhidrosis.”

For a generalized hyperhidrosis, Dr. Cha recommends dermatologists take a thorough history and perform an exam to rule out a secondary hyperhidrosis.

“Once it is confirmed that it is a primary type, I consider starting systemic anticholinergics,” she says.

Credible hyperhidrosis patient resources including the International Hyperhidrosis Society, at SweatHelp.org, Hyperhidrosis UK, at HyperhidrosisUK.org, according to the paper.

Disclosures:

Dr. Cha reports no relevant disclosures.