Review Examines Local Procedures Treating Axillary Hyperhidrosis and Osmidrosis

A recent literature review published in the Journal of the European Academy of Dermatology and Venereology explored the use of prospective and controlled clinical trials of local procedures for axillary hyperhidrosis and osmidrosis.¹

The review addresses a current unmet need, as researchers Grove et al. noted that there is a lack of clinical evidence regarding the profiles of different procedural treatments for these conditions.

According to Grove et al., while botulinum toxin remains the gold standard of treatment for focal hyperhidrosis, energy-based options such as lasers, radio-frequencies, and microwave devices, as well as surgical procedures, including excision, liposuction and curettage, have also emerged as potential alternatives for more severe disease.²

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Background and Methods

To identify relevant clinical trials, researchers conducted a systematic search across multiple databases including PubMed, Embase, and the Cochrane Library. The search, dated up to December 31, 2023, utilized a combination of keywords and Medical Subject Headings and a collaboration with an information specialist at Copenhagen University Library.

The study focused on patients with axillary hyperhidrosis and/or axillary osmidrosis with an emphasis on local procedures in prospective and controlled studies. Studies on healthy individuals, non-local procedures like sympathectomy, and retrospective designs, were excluded from review.

Two authors independently evaluated studies using the Rayyan web tool, with the initial screening involving an assessment of titles and abstracts and a review of full-text articles. They extracted relevant data, including study characteristics, intervention details, outcome measures, and primary findings.

Key domains included randomization, allocation concealment, blinding, and loss to follow-up. Each domain was assessed via categorization of low, high, or unclear risk of bias.

Findings

The initial search yielded a total of 2064 records. Upon the removal of duplicate papers, record screening, and assessing for eligibility, 59 records were included in the review.

Of these, 28 involved the use of botulinum toxins, 11 involved energy-based devices, 6 involved surgical interventions, and the remaining 14 involved alternative or combined approaches utilizing the modalities listed above. The majority of records focused primarily on hyperhidrosis (n=43), while significantly fewer focused primarily on osmidrosis (n=7). Slightly more (n=9) explored both conditions.

The studies primarily made use of measures of gravimetry, transepidermal water loss, skin conductance, and subjective sweat and odor scales.

Botulinum toxin studies varied in types and doses of botulinum toxin used, alongside different delivery methods, with most focusing on hyperhidrosis treatment. Patient satisfaction was high, and side effects were generally minor, with transient compensatory sweating being a notable concern.

Studies on established treatment options like microwave thermolysis, diode-lasers, RF-MN, Nd:YAG laser, CO2 laser, IPL, and ultrasound revealed varying efficacy in reducing sweating, with adverse effects mainly limited to mild skin reactions.

Surgical interventions, including liposuction-curettage and subdermal shaving, showed effectiveness in treating both hyperhidrosis and osmidrosis, with generally manageable side effects such as pain and bruising.

Alternative interventions such as iontophoresis and alkali patch therapy demonstrated some efficacy, but were generally less effective or more painful compared to traditional treatments like botulinum toxin injections.

Among the studies, 23 demonstrated a clear randomization process, with 12 ensuring proper allocation to treatment. Twenty-nine studies had blinded outcome assessments, with 20 being double-blinded. Most studies had minimal loss to follow-up, with only 48 reporting no more than 20%.

Studies of botulinum toxin showed the lowest bias risk, while surgical intervention studies had the highest.

Conclusions

A potential limitation of the review, as noted by its authors, includes the assessment of exclusively prospective and controlled trials. This, they noted, may have meant the removal of early-stage experimental treatments from their consideration. Additionally, they noted that assessing outcomes for hyperhidrosis and osmidrosis poses challenges, as measures of sweat, sweat rates, and patient-reported outcome measures may make comparison challenging, and even introduce recall and timing biases.

Researchers noted that moving forward, a better understanding of these varied treatment modalities among clinicians is crucial. They also called for future studies of a randomized, controlled nature when exploring such modalities, and they noted that establishing core outcome sets for these conditions may assist in future studies.

"In the continuous effort to provide accurate, evidence-based patient information and treatment, further high-quality studies investigating the newer, less-established treatments are called for," according to Grove et al. "Comparing their efficacy with conventional treatments, and a continuous review of the existing literature, is adamant."

References

1. Grove GL, Henning MAS, Togsverd-Bo K, et al. Local procedures for axillary hyperhidrosis and osmidrosis: A systematic review of prospective and controlled clinical trials. J Eur Acad Dermatol Venereol. May 9, 2024. https://doi.org/10.1002/jvc2.415
2. Glaser DA, Galperin TA. Local procedural approaches for axillary hyperhidrosis. Dermatol Clin. 2014; 32(4): 533–540. https://doi.org/10.1016/j.det.2014.06.014