New and existing hyperhidrosis treatments offer improved quality of life

ORLANDO – About 8 million people in the United States are diagnosed with hyperhidrosis, including about 1.6% of adolescents and 0.6% of prepubertal children.

Strikingly, about 70% of patients with symptoms of hyperhidrosis do not consult a physician about their symptoms, but it is likely they are well aware that something isn’t right; patients with hyperhidrosis sweat at a rate that is about four to five times greater than that in healthy controls, according to Dr. Adam Friedman.

Hyperhidrosis peaks between the ages of 18 and 54 years – the prime college and working years – so the impact on day-to-day activities can be substantial, if not disabling. In fact, patients rate the effects of hyperhidrosis on quality of life as greater than those associated with psoriasis and eczema. Similarly, school-age children can be dramatically affected by the condition, as handwriting, keeping papers and keyboards dry, sports activities, and use of handheld electronics pose specific challenges, Dr. Friedman said at the Orlando Dermatology Aesthetic and Clinical conference.

Patients may have general or focal hyperhidrosis. General hyperhidrosis can be secondary to any number of substances or conditions, including drugs, toxins, substance use, cardiovascular disorders, respiratory failure, infections, malignancies, or endocrine/metabolic disorders. Focal hyperhidrosis may be primary idiopathic, associated with neuropathies, or secondary to spinal disease or injury.

There is no known etiology, but genetics may play a role; 65% of patients in one study reported a family history of the condition.

When evaluating patients, begin with a review of systems, especially if there is concern that the hyperhidrosis is secondary to another condition. Ask about age of onset, location (about half of all patients have axillary hyperhidrosis), triggers, and symptoms. Perform a physical exam, looking for any anatomical abnormalities, as postsurgical anatomic abnormalities are a major cause of focal hyperhidrosis, and be sure to ask patients about the extent of their symptoms and the effects of the disease on their daily activities, advised Dr. Friedman, director of dermatologic research at the Albert Einstein College of Medicine, New York.

In terms of laboratory evaluation, gravimetric testing is “the golden tool” for research, but a starch iodine test to define the extent and areas of disease is the best clinical tool, he said.

A primary hyperhidrosis diagnosis requires that the patients have focal, visible, excessive sweating of 6 months duration with no apparent cause, and two of the following: bilateral and symmetric sweating, impairment of daily activities, at least one episode per week, onset of less than 25 years, positive family history, and cessation during sleep.

Noninvasive treatment options include topical antiperspirants and other topical agents, systemic medications, and iontophoresis, and minimally invasive options include botulinum toxin injections and energy-based treatments.

The standard, first-line, go-to topical treatment is aluminum salts, which come in a variety of formulations. The concentration used depends on the area affected. For example, 10%-25% can be used for the axillae, and 30%-40% can be used for the palms and soles.

Over-the-counter clinical strength products also are available and are formulated to cause less skin irritation.

Optimal use of topical treatments requires that the product remain on the skin for 6-8 hours. Overnight application is ideal, because patients typically don’t sweat at night, Dr. Friedman said, adding that the medication should be washed off before daytime sweating begins.

Nonmedicated deodorant can be used in the morning after bathing.

Dr. Friedman also recommended waiting 24-48 hours after shaving to apply topical medications, and he noted that patients should be advised to wear white or light-colored clothing, as aluminum salts will stain.

Additionally, prewashing the area to be treated is not advisable, as this introduces moisture, which can form hydrochloric acid when combined with the aluminum chloride. If irritation does occur, treat with low-potency topical steroids.

Pediatric use of topical treatments has not been specifically studied, but treatment is generally the same as in older patients. However, compliance can be a problem.

“I usually recommend application every night for the first month under occlusion with a tight-fitting white T-shirt, and then three times per week thereafter,” he said.

Noninvasive treatments are pretty simple, but require educating the patients to ensure correct use, he noted.

Keep in mind that many insurance companies consider other treatments, including iontophoresis and onabotulinumtoxinA to be medically necessary only when topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash, he added.

As for systemic agents, none have been specifically tested for hyperhidrosis in clinical trials, so use is off-label and based on case reports or small case series. Anticholinergics, including glycopyrrolate and oxybutynin, have been used with some success.

“I actually prefer glycopyrrolate, because it does not cross the blood-brain barrier, so it is associated with fewer overall systemic and neurologic side effects,” Dr. Friedman said, noting that he starts with 1 mg twice daily, titrated slowly up to a maximum of 6 mg daily.

An oral solution is available, which is useful for treating children, he said, noting that data suggest anticholinergics can be very effective in children. In one recent study, 90% of 31 children treated with an average dose of 2 mg per day of glycopyrrolate experienced improvement (J. Am. Acad. Dermatol. 2012;67:918-23). In a review of 59 children treated with oxybutynin for palmar-plantar hyperhidrosis titrated up to 5 mg twice daily, 90% experienced improvement (Pediatr. Dermatol. 2014 Dec. 10 [doi:10.1111/pde.12385]). Central nervous system side effects were more common in the latter study, however.

The downside of using anticholinergics is the need for long-term therapy and the long list of possible side effects, including dry mouth, dry eyes, constipation, blurred vision, and urinary retention – among many others, he said.

For patients with hyperhidrosis due to social phobia and performance anxiety, consider using beta-blockers. Give 10-20 mg about an hour before performance, or 5 mg in those with low blood pressure, slow baseline heart rate, or very small body mass index. A trial run at home before a performance is advisable. A number of contraindications to beta-blocker use exist, including bradycardia, atrioventricular block, and asthma, just to name a few, Dr. Friedman said.

Minimally invasive treatment options include botulinum toxin injections and energy based treatments.

Botulinum toxin injections last 3-7 months and are quite effective, with 90% of patients reporting improvement, but they can be painful and are expensive at $1,400-$1,600 per treatment.

Among new and emerging treatments that show promise are MiraDry, a microwave energy technology approved in 2011 for axillary hyperhidrosis, and topical botulinum toxin, delivered without needles thanks to nanotechnology.

The latter is currently under development by at least two companies, and trials are underway. Early data suggest treatment reduces sweating by 40%, Dr. Friedman said.

Dr. Friedman reported having no relevant financial disclosures.

ORLANDO – About 8 million people in the United States are diagnosed with hyperhidrosis, including about 1.6% of adolescents and 0.6% of prepubertal children.

Strikingly, about 70% of patients with symptoms of hyperhidrosis do not consult a physician about their symptoms, but it is likely they are well aware that something isn’t right; patients with hyperhidrosis sweat at a rate that is about four to five times greater than that in healthy controls, according to Dr. Adam Friedman.

Hyperhidrosis peaks between the ages of 18 and 54 years – the prime college and working years – so the impact on day-to-day activities can be substantial, if not disabling. In fact, patients rate the effects of hyperhidrosis on quality of life as greater than those associated with psoriasis and eczema. Similarly, school-age children can be dramatically affected by the condition, as handwriting, keeping papers and keyboards dry, sports activities, and use of handheld electronics pose specific challenges, Dr. Friedman said at the Orlando Dermatology Aesthetic and Clinical conference.

Patients may have general or focal hyperhidrosis. General hyperhidrosis can be secondary to any number of substances or conditions, including drugs, toxins, substance use, cardiovascular disorders, respiratory failure, infections, malignancies, or endocrine/metabolic disorders. Focal hyperhidrosis may be primary idiopathic, associated with neuropathies, or secondary to spinal disease or injury.

There is no known etiology, but genetics may play a role; 65% of patients in one study reported a family history of the condition.

When evaluating patients, begin with a review of systems, especially if there is concern that the hyperhidrosis is secondary to another condition. Ask about age of onset, location (about half of all patients have axillary hyperhidrosis), triggers, and symptoms. Perform a physical exam, looking for any anatomical abnormalities, as postsurgical anatomic abnormalities are a major cause of focal hyperhidrosis, and be sure to ask patients about the extent of their symptoms and the effects of the disease on their daily activities, advised Dr. Friedman, director of dermatologic research at the Albert Einstein College of Medicine, New York.

In terms of laboratory evaluation, gravimetric testing is “the golden tool” for research, but a starch iodine test to define the extent and areas of disease is the best clinical tool, he said.

A primary hyperhidrosis diagnosis requires that the patients have focal, visible, excessive sweating of 6 months duration with no apparent cause, and two of the following: bilateral and symmetric sweating, impairment of daily activities, at least one episode per week, onset of less than 25 years, positive family history, and cessation during sleep.

Noninvasive treatment options include topical antiperspirants and other topical agents, systemic medications, and iontophoresis, and minimally invasive options include botulinum toxin injections and energy-based treatments.

The standard, first-line, go-to topical treatment is aluminum salts, which come in a variety of formulations. The concentration used depends on the area affected. For example, 10%-25% can be used for the axillae, and 30%-40% can be used for the palms and soles.

Over-the-counter clinical strength products also are available and are formulated to cause less skin irritation.

Optimal use of topical treatments requires that the product remain on the skin for 6-8 hours. Overnight application is ideal, because patients typically don’t sweat at night, Dr. Friedman said, adding that the medication should be washed off before daytime sweating begins.

Nonmedicated deodorant can be used in the morning after bathing.

Dr. Friedman also recommended waiting 24-48 hours after shaving to apply topical medications, and he noted that patients should be advised to wear white or light-colored clothing, as aluminum salts will stain.

Additionally, prewashing the area to be treated is not advisable, as this introduces moisture, which can form hydrochloric acid when combined with the aluminum chloride. If irritation does occur, treat with low-potency topical steroids.

Pediatric use of topical treatments has not been specifically studied, but treatment is generally the same as in older patients. However, compliance can be a problem.

“I usually recommend application every night for the first month under occlusion with a tight-fitting white T-shirt, and then three times per week thereafter,” he said.

Noninvasive treatments are pretty simple, but require educating the patients to ensure correct use, he noted.

Keep in mind that many insurance companies consider other treatments, including iontophoresis and onabotulinumtoxinA to be medically necessary only when topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash, he added.

As for systemic agents, none have been specifically tested for hyperhidrosis in clinical trials, so use is off-label and based on case reports or small case series. Anticholinergics, including glycopyrrolate and oxybutynin, have been used with some success.

“I actually prefer glycopyrrolate, because it does not cross the blood-brain barrier, so it is associated with fewer overall systemic and neurologic side effects,” Dr. Friedman said, noting that he starts with 1 mg twice daily, titrated slowly up to a maximum of 6 mg daily.

An oral solution is available, which is useful for treating children, he said, noting that data suggest anticholinergics can be very effective in children. In one recent study, 90% of 31 children treated with an average dose of 2 mg per day of glycopyrrolate experienced improvement (J. Am. Acad. Dermatol. 2012;67:918-23). In a review of 59 children treated with oxybutynin for palmar-plantar hyperhidrosis titrated up to 5 mg twice daily, 90% experienced improvement (Pediatr. Dermatol. 2014 Dec. 10 [doi:10.1111/pde.12385]). Central nervous system side effects were more common in the latter study, however.

The downside of using anticholinergics is the need for long-term therapy and the long list of possible side effects, including dry mouth, dry eyes, constipation, blurred vision, and urinary retention – among many others, he said.

For patients with hyperhidrosis due to social phobia and performance anxiety, consider using beta-blockers. Give 10-20 mg about an hour before performance, or 5 mg in those with low blood pressure, slow baseline heart rate, or very small body mass index. A trial run at home before a performance is advisable. A number of contraindications to beta-blocker use exist, including bradycardia, atrioventricular block, and asthma, just to name a few, Dr. Friedman said.

Minimally invasive treatment options include botulinum toxin injections and energy based treatments.

Botulinum toxin injections last 3-7 months and are quite effective, with 90% of patients reporting improvement, but they can be painful and are expensive at $1,400-$1,600 per treatment.

Among new and emerging treatments that show promise are MiraDry, a microwave energy technology approved in 2011 for axillary hyperhidrosis, and topical botulinum toxin, delivered without needles thanks to nanotechnology.

The latter is currently under development by at least two companies, and trials are underway. Early data suggest treatment reduces sweating by 40%, Dr. Friedman said.

Dr. Friedman reported having no relevant financial disclosures.

ORLANDO – About 8 million people in the United States are diagnosed with hyperhidrosis, including about 1.6% of adolescents and 0.6% of prepubertal children.

Strikingly, about 70% of patients with symptoms of hyperhidrosis do not consult a physician about their symptoms, but it is likely they are well aware that something isn’t right; patients with hyperhidrosis sweat at a rate that is about four to five times greater than that in healthy controls, according to Dr. Adam Friedman.

Hyperhidrosis peaks between the ages of 18 and 54 years – the prime college and working years – so the impact on day-to-day activities can be substantial, if not disabling. In fact, patients rate the effects of hyperhidrosis on quality of life as greater than those associated with psoriasis and eczema. Similarly, school-age children can be dramatically affected by the condition, as handwriting, keeping papers and keyboards dry, sports activities, and use of handheld electronics pose specific challenges, Dr. Friedman said at the Orlando Dermatology Aesthetic and Clinical conference.

Patients may have general or focal hyperhidrosis. General hyperhidrosis can be secondary to any number of substances or conditions, including drugs, toxins, substance use, cardiovascular disorders, respiratory failure, infections, malignancies, or endocrine/metabolic disorders. Focal hyperhidrosis may be primary idiopathic, associated with neuropathies, or secondary to spinal disease or injury.

There is no known etiology, but genetics may play a role; 65% of patients in one study reported a family history of the condition.

When evaluating patients, begin with a review of systems, especially if there is concern that the hyperhidrosis is secondary to another condition. Ask about age of onset, location (about half of all patients have axillary hyperhidrosis), triggers, and symptoms. Perform a physical exam, looking for any anatomical abnormalities, as postsurgical anatomic abnormalities are a major cause of focal hyperhidrosis, and be sure to ask patients about the extent of their symptoms and the effects of the disease on their daily activities, advised Dr. Friedman, director of dermatologic research at the Albert Einstein College of Medicine, New York.

In terms of laboratory evaluation, gravimetric testing is “the golden tool” for research, but a starch iodine test to define the extent and areas of disease is the best clinical tool, he said.

A primary hyperhidrosis diagnosis requires that the patients have focal, visible, excessive sweating of 6 months duration with no apparent cause, and two of the following: bilateral and symmetric sweating, impairment of daily activities, at least one episode per week, onset of less than 25 years, positive family history, and cessation during sleep.

Noninvasive treatment options include topical antiperspirants and other topical agents, systemic medications, and iontophoresis, and minimally invasive options include botulinum toxin injections and energy-based treatments.

The standard, first-line, go-to topical treatment is aluminum salts, which come in a variety of formulations. The concentration used depends on the area affected. For example, 10%-25% can be used for the axillae, and 30%-40% can be used for the palms and soles.

Over-the-counter clinical strength products also are available and are formulated to cause less skin irritation.

Optimal use of topical treatments requires that the product remain on the skin for 6-8 hours. Overnight application is ideal, because patients typically don’t sweat at night, Dr. Friedman said, adding that the medication should be washed off before daytime sweating begins.

Nonmedicated deodorant can be used in the morning after bathing.

Dr. Friedman also recommended waiting 24-48 hours after shaving to apply topical medications, and he noted that patients should be advised to wear white or light-colored clothing, as aluminum salts will stain.

Additionally, prewashing the area to be treated is not advisable, as this introduces moisture, which can form hydrochloric acid when combined with the aluminum chloride. If irritation does occur, treat with low-potency topical steroids.

Pediatric use of topical treatments has not been specifically studied, but treatment is generally the same as in older patients. However, compliance can be a problem.

“I usually recommend application every night for the first month under occlusion with a tight-fitting white T-shirt, and then three times per week thereafter,” he said.

Noninvasive treatments are pretty simple, but require educating the patients to ensure correct use, he noted.

Keep in mind that many insurance companies consider other treatments, including iontophoresis and onabotulinumtoxinA to be medically necessary only when topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash, he added.

As for systemic agents, none have been specifically tested for hyperhidrosis in clinical trials, so use is off-label and based on case reports or small case series. Anticholinergics, including glycopyrrolate and oxybutynin, have been used with some success.

“I actually prefer glycopyrrolate, because it does not cross the blood-brain barrier, so it is associated with fewer overall systemic and neurologic side effects,” Dr. Friedman said, noting that he starts with 1 mg twice daily, titrated slowly up to a maximum of 6 mg daily.

An oral solution is available, which is useful for treating children, he said, noting that data suggest anticholinergics can be very effective in children. In one recent study, 90% of 31 children treated with an average dose of 2 mg per day of glycopyrrolate experienced improvement (J. Am. Acad. Dermatol. 2012;67:918-23). In a review of 59 children treated with oxybutynin for palmar-plantar hyperhidrosis titrated up to 5 mg twice daily, 90% experienced improvement (Pediatr. Dermatol. 2014 Dec. 10 [doi:10.1111/pde.12385]). Central nervous system side effects were more common in the latter study, however.

The downside of using anticholinergics is the need for long-term therapy and the long list of possible side effects, including dry mouth, dry eyes, constipation, blurred vision, and urinary retention – among many others, he said.

For patients with hyperhidrosis due to social phobia and performance anxiety, consider using beta-blockers. Give 10-20 mg about an hour before performance, or 5 mg in those with low blood pressure, slow baseline heart rate, or very small body mass index. A trial run at home before a performance is advisable. A number of contraindications to beta-blocker use exist, including bradycardia, atrioventricular block, and asthma, just to name a few, Dr. Friedman said.

Minimally invasive treatment options include botulinum toxin injections and energy based treatments.

Botulinum toxin injections last 3-7 months and are quite effective, with 90% of patients reporting improvement, but they can be painful and are expensive at $1,400-$1,600 per treatment.

Among new and emerging treatments that show promise are MiraDry, a microwave energy technology approved in 2011 for axillary hyperhidrosis, and topical botulinum toxin, delivered without needles thanks to nanotechnology.

The latter is currently under development by at least two companies, and trials are underway. Early data suggest treatment reduces sweating by 40%, Dr. Friedman said.

Dr. Friedman reported having no relevant financial disclosures.