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Hyperhidrosis: The Patient’s Perspective

Hyperhidrosis: The Patient’s Perspective.

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Hyperhidrosis: The Patient’s Perspective

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  1. 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 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. 1998;580:27-32. 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. 1968;98:505-507. Levit F. Cutis. 1980;26:192-194.

  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. 1994;220:86-90. 2Zacherl J, et al. Eur J Surg. 1998;43-46.

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

  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 Hyperhidrosis:Clinical 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. 2001;323:596-599.

  15. 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 • 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. 2001;323:596-599.

  16. BTX-A: Clinical Trial Results at 4 Weeks * * *P < 0.001 vs placebo. Naumann M, et al. BMJ. 2001;323:596-599.

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