Hyperhidrosis The Patient s Perspective I can t buy nice

Hyperhidrosis: The Patient’s 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 airdryer 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

Hyperhidrosis l 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 l Cutaneous effects include dehydration, maceration, and secondary infections l

Types of Hyperhidrosis l 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 l Generalized hyperhidrosis – Excessive sweating over entire body – Causes include diabetes, chronic infectious diseases, malignancy

Psychiatric Aspects of Hyperhidrosis can be secondary to social anxiety disorder (SAD) l In 1 study, 1 endoscopic thoracic sympathectomy significantly relieved hyperhidrosis and other symptoms such as blushing and trembling hands in SAD patients l Other treatments explored in SAD patients 2 l – Selective serotonin reuptake inhibitors (53% reduction in sweating) – GABAergic anticonvulsant (40% reduction) – Cognitive behavior therapy (25% reduction) 1 Telaranta T. Eur J Surg. 1998; 580: 27 -32. 2 Davidson JR, et al. Submitted.

Hyperhidrosis Treatments l l l Antiperspirants and deodorants Iontophoresis Anticholinergic drugs Local surgical excision Endoscopic thoracic sympathectomy Botulinum toxin A

Antiperspirants and Deodorants l Antiperspirant – Astringent that decreases eccrine and apocrine sweat secretion l 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

Iontophoresis l l l 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 patients 1 Side effects include dry, cracked, fissured skin in treated area 1 Levit F. Arch Dermatol. 1968; 98: 505 -507. Levit F. Cutis. 1980; 26: 192 -194.

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

Local Surgical Management l 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 l Side effects include bleeding, hematomas, scars, infection l

Endoscopic Thoracic Sympathectomy (ETS) ETS has superseded conventional open surgery l Minimally invasive video-assisted surgical techniques have increased acceptance l Usual technique is to destroy thoracic sympathetic ganglia T 2 and T 3 by electrocautery (palmar hyperhidrosis) l T 4 also destroyed in treatment of axillary hyperhidrosis l

ETS: Efficacy and Complications l l l Approximately 98% of patients treated for palmar hyperhidrosis achieve immediate, complete anhidrosis 1 In axillary hyperhidrosis, 83% of treated patients had dry skin postoperatively; 68% had dry skin at long-term followup 2 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. 1 Herbst F, et al. Ann Surg. 1994; 220: 86 -90. 2 Zacherl J, et al. Eur J Surg. 1998; 43 -46.

ETS: Clinical Trial Results Zacherl J, et al. Eur J Surg. 1998; 43 -46.

Botulinum Toxin A (BTX-A) Novel, minimally invasive treatment l Temporarily blocks release of acetylcholine from cholinergic sudomotor fibers l Injected intradermally into hyperhidrotic areas l

BTX-A in Axillary Hyperhidrosis: Clinical Trial Objective and Design l Objective – Evaluate the safety and efficacy of BTX-A in treatment of bilateral axillary hyperhidrosis l Design – Randomized, parallel-group, double-blind, placebo-controlled trial l Patients – 307 patients aged 17 -75 years with bilateral axillary hyperhidrosis severe enough to interfere with daily life l 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. 2001; 323: 596 -599.

BTX-A in Axillary Hyperhidrosis: Clinical Trial Results At Week 4, 93. 8% of patients treated with BTX-A were classified as responders (>50% reduction in sweat production) vs 35. 9% of the placebo-treated group l 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 l 207 patients were followed for 12 more months l Mean duration of benefit from a single BTX-A treatment was 7 months l Naumann M, et al. BMJ. 2001; 323: 596 -599.

BTX-A: Clinical Trial Results at 4 Weeks * * *P < 0. 001 vs placebo. Naumann M, et al. BMJ. 2001; 323: 596 -599.