Hyperhidrosis and bromhidrosis -- a guide to assessment and management

BACKGROUND

Hyperhidrosis and bromhidrosis are two common conditions, which are troublesome for patients and carry a significant psychosocial burden.

OBJECTIVE

This article details an approach to the assessment and management of hyperhidrosis and bromhidrosis, and outlines current treatment options.

DISCUSSION

Hyperhidrosis can be either generalised or focal. Generalised hyperhidrosis may be primary and idiopathic or secondary to systemic disease. Treatment may require oral anticholinergic agents. Focal hyperhidrosis is usually primary and responds to topical measures. Specialist referral for botulinum toxin A, iontophoresis or sympathectomy should be considered for severe cases. Bromhidrosis usually responds to antiperspirants, fragrance and antibacterial agents.

The effectiveness of tap water iontophoresis for palmoplantar hyperhidrosis using a Monday, Wednesday, and Friday treatment regime

Primary focal hyperhidrosis is a benign condition of unknown etiology. Tap water iontophoresis has long been known to inhibit sweat production. The mechanism of reduced hyperhidrosis by iontophoresis is not completely clear. For operational convenience, our patients received their treatments at different intervals to those recommended by the manufacturer of the iontophoresis unit. We performed a retrospective audit to evaluate the effectiveness of tap water iontophoresis using this regimen. This new treatment regimen was effective at controlling palmoplantar hyperhidrosis. Minimal undesirable effects such as mild skin irritation and erythema were noted but none were severe enough to necessitate discontinuation of treatment. In conclusion, tap water iontophoresis is a safe and effective treatment of palmar and plantar hyperhidrosis when used on Monday, Wednesday, and Friday for 4 weeks. Continued treatment is needed to maintain the effect and many patients go on to purchase their own machines. This technique should be considered prior to systemic or aggressive surgical intervention.

Treatment options for hyperhidrosis

Hyperhidrosis is a disorder of excessive sweating beyond what is expected for thermoregulatory needs and environmental conditions. Primary hyperhidrosis has an estimated prevalence of nearly 3% and is associated with significant medical and psychosocial consequences. Most cases of hyperhidrosis involve areas of high eccrine density, particularly the axillae, palms, and soles, and less often the craniofacial area. Multiple therapies are available for the treatment of hyperhidrosis. Options include topical medications (most commonly aluminum chloride), iontophoresis, botulinum toxin injections, systemic medications (including glycopyrrolate and clonidine), and surgery (most commonly endoscopic thoracic sympathectomy [ETS]). The purpose of this article is to comprehensively review the literature on the subject, with a focus on new and emerging treatment options. Updated therapeutic algorithms are proposed for each commonly affected anatomic site, with practical procedural guidelines. For axillary and palmoplantar hyperhidrosis, topical treatment is recommended as first-line treatment. For axillary hyperhidrosis, botulinum toxin injections are recommended as second-line treatment, oral medications as third-line treatment, local surgery as fourth-line treatment, and ETS as fifth-line treatment. For palmar and plantar hyperhidrosis, we consider a trial of oral medications (glycopyrrolate 1-2 mg once or twice daily preferred to clonidine 0.1 mg twice daily) as second-line therapy due to the low cost, convenience, and emerging literature supporting their excellent safety and reasonable efficacy. Iontophoresis is considered third-line therapy for palmoplantar hyperhidrosis; efficacy is high although so are the initial levels of cost and inconvenience. Botulinum toxin injections are considered fourth-line treatment for palmoplantar hyperhidrosis; efficacy is high though the treatment remains expensive, must be repeated every 3-6 months, and is associated with pain and/or anesthesia-related complications. ETS is a fifth-line option for palmar hyperhidrosis but is not recommended for plantar hyperhidrosis due to anatomic risks. For craniofacial hyperhidrosis, oral medications (either glycopyrrolate or clonidine) are considered first-line therapy. Topical medications or botulinum toxin injections may be useful in some cases and ETS is an option for severe craniofacial hyperhidrosis.

[Structure of the sweat glands in essential axillar hyperhidrosis and after its surgical treatment]

The structure of sweat glands in their skin portions in axillar regions was investigated in essential hyperhydrosis and after its treatment using mechanical curettage, performed solely or in combination with ultrasonic destruction. There was shown, that hyperhydrosis is accompanied by the sweat glands canaliculus secretory portion enlargement and their diameter as well. Additionally, the secretory epithelium area is practically enhanced twice as in a control and its thickness - in 1.5 times. Curettage is accompanied with removal, along with hypoderma, of majority of the sweat glands terminal portions and, due to evolvement of a dense connective tissue regenerate, prophylaxes their regeneration with a staged hypotrophy of residual secretory portions. The combined application of curettage with ultrasonic destruction, during treatment of hyperhydrosis, secures more prominent, alike while only curettage performance, reduction of terminal parts of sweat glands. It takes place on background of the inflammatory reaction reduction and the connective tissue subtle regenerate formation. Surgical methods of treatment, alike botulotoxin injections, secures more pronounced and persistent reduction of sweat glands in hyperhydrosis.

No sweat

When nurse Julie Halford discovered what misery hyperhidrosis causes, she was determined to help.

Sweaty, smelly hands and feet

BACKGROUND

Palmoplantar hyperhidrosis, with or without offensive odour (bromhidrosis), can have a devastating effect on a patient's life. The condition usually begins in childhood or adolescence and can impact greatly on education, career choices and social development.

OBJECTIVE

This article describes the presentation, investigation and management options for palmoplantar hyperhidrosis.

DISCUSSION

Clinical history and examination is often sufficient to make a diagnosis of palmoplantar hyperhidrosis. Fortunately, there are successful treatments available that can provide relief of symptoms.

Treatment of axillary hyperhidrosis/bromidrosis using VASER ultrasound

BACKGROUND

Current methods of treatment for axillary hyperhidrosis and/or bromidrosis are palliative (use of topical aluminum chloride or injections of botulinum toxin type A) or surgically based for more permanence (excisional surgery, endoscopic transthoracic sympathectomy, liposuction/curettage). The surgical approaches have mixed effectiveness and incur the risk of significant side effects and complications.

METHODS

Thirteen patients (3 males, 10 females) with significant axillary hyperhidrosis and/or bromidrosis were recruited, treated with the VASER ultrasound, and followed for 6 months. Preoperative assessment of the impact of hyperhidrosis and/or bromidrosis on lifestyle and the degree of sweat/odor were completed. Postoperative assessment of changes relative to lifestyle and degree of sweat/odor reduction and patient and surgeon satisfaction were completed.

RESULTS

Eleven of 13 patients had significant reduction in sweat/odor and had no recurrence of significant symptoms at 6 months. Two patients had a reduction in sweat/odor but not to the degree desired by the patients. No significant complications were noted. A simple amplitude and time protocol was established that provides consistent and predictable therapy. The complete procedure takes less than 1 h to treat two axillae using local anesthetic.

CONCLUSION

The VASER is safe and effective for treatment of axillary hyperhidrosis/bromidrosis. The method is minimally invasive with immediate return to basic activities and only temporary minor restriction of arm movement. At 6 months the treatment appears to be long-lasting, but further follow-up is required for verification of permanence. This method has become the standard of care for the treatment of axillary hyperhidrosis/bromidrosis in the authors' practice.

[Esthetic and corrective dermatology: clinical applications and social role]

Skin diseases may have severe aesthetic and psychological repercussions leading sometimes to discriminations and social isolation. Dermatologists have contributed to the development of many cosmetic procedures: peelings, botulinum toxin or hyaluronic acid injections, lasers, blepharoplasty, facelift, etc. Many of these treatments have interesting clinical applications and may help numerous patients with skin diseases to return to a normal social life.

A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee

BACKGROUND

Hyperhidrosis can have profound effects on a patient's quality of life. Current treatment guidelines ignore disease severity.

OBJECTIVE

The objective was to establish clinical guidelines for the recognition, diagnosis, and treatment of primary focal hyperhidrosis.

METHODS AND MATERIALS

A working group of eight nationally recognized experts was convened to develop the consensus statement using an evidence-based approach.

RECOMMENDATIONS

An algorithm was designed to consider both disease severity and location. The Hyperhidrosis Disease Severity Scale (HDSS) provides a qualitative measure that allows tailoring of treatment. Mild axillary, palmar, and plantar hyperhidrosis (HDSS score of 2) should initially be treated with topical aluminum chloride (AC). If the patient fails to respond to AC therapy, botulinum toxin A (BTX-A; axillae, palms, soles) and iontophoresis (palms, soles) should be the second-line therapy. In severe cases of axillary, palmar, and plantar hyperhidrosis (HDSS score of 3 or 4), both BTX-A and topical AC are first-line therapy. Iontophoresis is also first-line therapy for palmar and plantar hyperhidrosis. Craniofacial hyperhidrosis should be treated with oral medications, BTX-A, or topical AC as first-line therapy. Local surgery (axillary) and endoscopic thoracic sympathectomy (palms and soles) should only be considered after failure of all other treatment options.

CONCLUSIONS

These guidelines offer a rapid method to assess disease severity and to treat primary focal hyperhidrosis according to severity.

Treatment of focal hyperhidrosis

BACKGROUND

Focal hyperhidrosis is not rare, affecting over 2.5% of the population. This condition is often socially and professionally debilitating, leading to significant quality of life impairment. It most commonly involves the axillae, palms, soles, and face.

OBJECTIVE

To review hyperhidrosis and discuss and compare the treatment options currently available.

CONCLUSIONS

Topical or systemic therapies may be helpful for patients with mild disease. Invasive surgical options, although often effective, are limited by complications. More recently, botulinum toxin injection has proven to be a safe and successful treatment for hyperhidrosis and results in high patient satisfaction. Botulinum toxin A (Botox, Allergan Inc., Irvine, CA) is currently approved in the United States, Canada, the United Kingdom, and many other countries for the treatment of axillary hyperhidrosis and is routinely used off-label for other anatomic sites.

Primary focal hyperhidrosis: scope of the problem

Focal hyperhidrosis (HH) can cause debilitating reductions in the physical and emotional quality of life (QOL) of patients, which can result in numerous restrictions of a patient's personal and professional lifestyle and activities. A variety of treatment options are available for primary focal HH, including topical and oral agents, tap water iontophoresis (TWI), botulinum toxin type A (BTX-A), and surgery. Studies evaluating BTX-A (Botox) treatment for palmar, plantar, and facial HH reveal that BTX-A provides effective treatment of primary focal HH, with a reasonable duration of effect, and has a good safety profile. Physicians should understand the impact of focal HH and the need to stay abreast of the available treatment options to provide the best care for patients.

Liposuktionskürettage versus Botox® bei axillärer Hyperhidrosis

BACKGROUND

Axillary hyperhidrosis is a dysfunction of the secretion of sweat glands. Conservative treatment modalities are mostly ineffective. Liposuction combined with subcutaneous curettage (TLC) destroys the sweat glands, while Botox injections inhibit the cholinergic transmission.

MATERIAL AND METHOD

Of a total of 88 patients, TLC was carried out in 47 and 41 patients received intradermal Botox injections. The effect of both forms of treatment on the quality of life was assessed using a specific hyperhidrosis questionnaire and was correlated with sweat volumes measured by gravimetry.

RESULTS

Follow-up after 6 months showed significantly changed sweat volumes of 52+/-41 mg/min of TLC patients versus 78+/-87 mg/min in the Botox group. In the TLC group 91% and in the Botox group 98% were satisfied with the result.

CONCLUSION

The stress of a single surgical intervention is to be weighed against the necessary repetitive application of multiple Botox injections. Both methods are superior to other, more radical surgical methods in terms of efficacy and complication rates. Botox and TLC lead to a significant improvement of the quality of life.

Current and emerging therapeutic modalities for hyperhidrosis, part 2: moderately invasive and invasive procedures

Hyperhidrosis (HH) hinders patient quality of life and causes the secondary effect of excess cutaneous sweat. Treatment modalities include conservative and noninvasive therapies such as topical agents and iontophoresis. This article reviews moderately invasive and invasive procedures, such as botulinum toxin, curettage, and endoscopic thoracic sympathectomy (ETS), and compares their advantages and disadvantages in safety and efficacy.

Current and emerging therapeutic modalities for hyperhidrosis, part 1: conservative and noninvasive treatments

Approximately 1% to 3% of the US population has hyperhidrosis (HH). HH can be an incapacitating medical condition because it not only hinders patient quality of life but also causes the secondary effect of excess cutaneous sweat. There is a broad spectrum of treatment modalities including topical and systemic therapies, iontophoresis, localized neuroinhibitory injections, and surgical interventions. This article reviews HH and the conservative treatments for the condition.

Diagnosis, Impact, and Management of Focal Hyperhidrosis: Treatment Review Including Botulinum Toxin Therapy

Idiopathic localized hyperhidrosis, called for hyperhidrosis, affects almost 3% of the US population. The most frequent anatomic sites of involvement include the axillae, palms, soles, and face. For those affected, this condition can be extremely socially debilitating and interfere with work activities. Until recently, frequently ineffective topical regimens or problematic surgical procedures have been the treatments of choice. Since 1996, intracutaneous injections of botulinum toxin have been used as a minimally invasive treatment for this condition with numerous studies documenting safety, efficacy, and extremely high levels of patient satisfaction. Botulinum toxin type A (Botox) was approved by the US Food and Drug Administration in 2004 for the treatment of axillary hyperhidrosis.

Tumescent Suction Curettage in the Treatment of Axillary Hyperhidrosis: Experience in 63 Patients

BACKGROUND

Axillary hyperhidrosis is a common and most distressing problem, which can be addressed by a variety of treatment modalities.

OBJECTIVE

To assess the value of tumescent suction curettage in the treatment of axillary hyperhidrosis.

METHODS

63 patients (39 female, 25 male; mean age 30.3 +/- 7.6 years) with axillary hyperhidrosis were enrolled in the study. All patients were treated in an outpatient setting with tumescent suction curettage of the axillary cavity, using two entry sites. The results were evaluated with the iodine-starch test after 4 weeks and after 6 months. Two years after the procedure, patient satisfaction was evaluated as 'satisfied', 'partially satisfied' or 'dissatisfied'.

RESULTS

None of the patients had early postoperative complications of infection or seroma. All patients had a marked reduction of hyperhidrosis after 4 weeks, confirmed by the iodine-starch test. After 6 months, 15 patients had high sweat rates and asked for repeat surgery. Two years after the procedure, 49 patients were satisfied, 11 patients were partially satisfied and 3 patients were dissatisfied.

CONCLUSION

Tumescent suction curettage is a safe and effective treatment of axillary hyperhidrosis resulting in a high level of patient satisfaction. Some patients will need repeat surgery. Suction curettage, however, should not be used as the first line of treatment in axillary hyperhidrosis.

Thoracic outlet syndrome: another cause for unilateral palmar hyperhidrosis

One of the most important therapeutic goal in hyperhidrosis treatment is to seek for the underlying cause and to tailor the treatment accordingly. A detailed history and prompt physical examination are needed to clarify the etiological factor. In this study, we report a 34-year-old woman with a diagnosis of thoracic outlet syndrome presenting with complaints of pain, numbness, and fatigue in her left arm and ipsilateral palmar hyperhidrosis. Thus, we want to highlight a specific potential cause of secondary hyperhidrosis, which can otherwise be easily overlooked, and furthermore, which has a completely different treatment strategy.

Quantitative effect of anodal current in the treatment of primary hyperhidrosis by direct electrical current

AIM

To determine the quantitative effect and technique of use of the anodal current for the treatment of palmoplantar hyperhidrosis on local areas of the palms and soles.

METHODS

Twelve patients (four males and eight females) with idiopathic palmoplantar hyperhidrosis were enrolled in this study. Having determined the initial sweat intensities of both hands using the pad glove method, direct electrical current (d.c.) treatment was applied to the palms of the patients using a complete regulated d.c. unit for which the current and potential ranges were 0-30 mA and 0-90 V, respectively. Electrodes were placed into two separate water plates, and covered with pad made from gauze and cotton material. The pads were moisturized with tap water for current conduction. The anodal current was applied to the right hands of six patients (group I) and to the left hands of the remainder (group II). After seven treatments had been completed for the palms, the final sweat intensities of the hands were measured.

RESULTS

In both groups, the final sweat intensities of the hands subjected to the anodal current were significantly decreased in comparison with the initial values, regardless of whether the anodal current was applied to the right or left hand (P < 0.05). In contrast, the final sweat intensities of the other hands subjected to the cathodal current were not significantly decreased (P > 0.05).

CONCLUSIONS

It can be concluded that the anodal current is more effective in reducing sweating on the palms when applied either to the right or left hand. In the treatment of palmoplantar or localized hyperhidrosis, the anodal current should be referenced first to treat the sweatier hand or foot, or a local hyperhidrotic area of the skin. The selection of the anodal current for one hand for the first five or seven sessions appears to be more effective than the use of polarity changes for each session.

Focal hyperhidrosis: diagnosis and management

Hyperhidrosis, a condition characterized by excessive sweating, can be generalized or focal. Generalized hyperhidrosis involves the entire body and is usually part of an underlying condition, most often an infectious, endocrine or neurologic disorder. Focal hyperhidrosis is idiopathic, occurring in otherwise healthy people. It affects 1 or more body areas, most often the palms, armpits, soles or face. Almost 3% of the general population, largely people aged between 25 and 64 years, experience hyperhidrosis. The condition carries a substantial psychological and social burden, since it interferes with daily activities. However, patients rarely seek a physician's help because many are unaware that they have a treatable medical disorder. Early detection and management of hyperhidrosis can significantly improve a patient's quality of life. There are various topical, systemic, surgical and nonsurgical treatments available with efficacy rates greater than 90%-95%.

Hyperhidrosis: evolving therapies for a well-established phenomenon

The socially embarrassing disorder of excessive sweating, or hyperhidrosis, and its treatment options are gaining widespread attention. In order of frequency, palmar-plantar, palmar-axillary, Isolated axillary, and cranlofacial hyperhidrosis are distinct disorders of sudomotor regulation. A common link among these disorders is an excessive, nonthermoregulatory sweat response often to emotional stimuli in body regions influenced by the anterior cingulate cortex as opposed to the thermoregulatory sweat response regulated by the preoptic-anterior hypothalamus. Diagnosis of these mechanistically ambiguous disorders is primarily from patient history and physical examination, whereas results of laboratory studies performed with indicator powder reveal the distribution and severity of resting hyperhidrosis and document the integrity of thermoregulatory sweating. Treatment options lie on a continuum based on the severity of hyperhidrosis and the risks and benefits of therapy. In general, therapy begins with antiperspirants or anticholinergics. Iontophoresis is available for palmar-plantar and axillary hyperhidrosis. Botulinum toxin type A or local excision/curettage is effective for isolated axillary hyperhidrosis not responsive to topical application of aluminum chloride. Endoscopic thoracic sympathectomy may be used for severe cases of palmar-plantar and palmar-axillary hyperhidrosis. No sole therapy of choice has emerged for craniofacial sweating. The long-term sequelae of hyperhidrosis and its treatment also are discussed.

[Therapeutic application of botulogenic toxin]

Botulogenic toxin infiltration for the treatment of idiopathic local hyperhidrosis is a safe and well tolerated procedure, with minimum side effects and with an effectiveness demonstrated throughout the years, especially in axillary hyperhidrosis; in the majority of patients with this condition is an effective alternative to surgery. In other locations, the results are more modest and the clinical experience more limited, which forces us to advise the surgery as alternative with an incidence far from desirable.