US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: Results from a national survey

Radiofrequency Microneedling in Treating Primary Hyperhidrosis: A Systematic Review and Meta-Analysis

BACKGROUND

Radiofrequency microneedling (RFM) is a potential treatment for primary hyperhidrosis. However, its efficacy is unclear, and treatment parameters and outcomes vary across studies.

OBJECTIVE

To understand the effect of RFM on treating primary hyperhidrosis, as measured by changes in the Hyperhidrosis Disease Severity Score (HDSS) before and after treatment, and to clearly define treatment settings most likely to optimize results.

MATERIALS AND METHODS

A systematic literature search utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted across PubMed, EMBASE, MEDLINE, Web of Science, and the Cochrane Library. Studies were evaluated for risk of bias via the ROBINS-I tool and Levels of Evidence/GRADE criteria. A random forest model identified RFM settings that predict HDSS score decrease.

RESULTS

Six publications met inclusion criteria. The level of evidence was classified as Grade B, indicating moderate quality. RFM intervention resulted in a mean HDSS score decrease of 1.63 (52% reduction, p < .05). The strongest predictors for HDSS score decrease were dwell time, energy, and depth, with feature importances of 0.43, 0.19, and 0.15 respectively.

CONCLUSION

Radiofrequency microneedling treatment significantly reduces HDSS scores in patients with primary hyperhidrosis. Moving forward, it would benefit physicians to standardize objective protocols in reporting RFM parameters and measuring outcomes.

Global research trends and hotspots of hyperhidrosis: a bibliometric analysis (2008-2023)

Background

Recent studies have demonstrated significant advancements in the treatment of hyperhidrosis. However, a bibliometric analysis of relevant studies in this field is notably lacking. This study aims to provide a detailed analysis of research trends and key areas of interest in hyperhidrosis over the last 16 years using bibliometric methods.

Methods

We searched the Web of Science Core Collection (WoSCC) database for hyperhidrosis-related publications from 2008 to 2023 and conducted bibliometric analysis using VOS viewer and the R package "bibliometrix."

Results

The main research institutions involved in this study are the University of São Paulo, Hospital Israelita Albert Einstein, Yonsei University and Fujian Medical University, with a total of 728 articles included from 52 countries. Authors from these institutions have published in top journals, with Dermatologic Surgery being the most popular journal and the Journal of the American Academy of Dermatology being the most cited. A total of 2,830 authors have contributed to this field, with prominent researchers including Nelson Wolosker, Paulo Kauffman, Pedro Puech-Leão, Jose Ribas Milanez de Campos, and Dee Anna Glaser. Nelson Wolosker stands out as the most co-cited author. The primary focus of research in this area is on the treatment of hyperhidrosis and the prevention of post-operative complications. Emerging re-search hotspots include keywords such as "botulinum toxin," "oxybutynin," "sympathectomy," "iontophoresis," and "compensatory sweating".

Conclusion

The most prevalent academic emphasis within this field remains the treatment of hyperhidrosis and the management of compensatory hyperhidrosis. Despite this academic preponderance, there is a compelling necessity to foster enhanced collaboration and exchange between disparate countries and institutions.

The comparative study of letibotulinum toxin A and onabotulinum toxin A in treatment of primary axillary hyperhidrosis

Primary axillary hyperhidrosis (PAH) is a challenging condition characterized by excessive underarm sweating. The U.S. Food and Drug Administration has approved onabotulinum toxin A (OnaBTX-A, Botox®, Allergan Inc, USA) as the only botulinum toxin treatment for severe axillary hyperhidrosis, and it has demonstrated positive results. Recently, the off-label use of letibotulinum toxin A (LetiBTX-A, Hugel®, Hugel Inc, Korea) has risen significantly for cosmetic purposes due to its effectiveness. For the treatment of primary axillary hyperhidrosis, the authors proposed that LetiBTX-A is at least as effective as OnaBTX-A. To evaluate the efficacy and safety of letibotulinum toxin A (LetiBTX-A) in comparison to onabotulinum toxin A (OnaBTX-A) for treating primary axillary hyperhidrosis (PAH). All participants with a diagnosis of moderate to severe primary axillary hyperhidrosis (Hyperhidrosis Disease Severity Scale (HDSS) score ≥ 2) received random injections of 50 U of LetiBTX-A in one armpit and 50 U of OnaBTX-A in the other site. HDSS score and hyperhidrosis area were measured by using the Minor's iodine starch test. Participant satisfaction was evaluated at 1, 3, and 6 months following the injection. Onset of action and adverse events were also assessed. All 30 participants completed the study protocol, with the mean age was 34.44 ± 7.82 years and most of the participants were female. The mean age at onset was 20.47 ± 3.01 years and more than 50% of participants had a HDSS score of 3. There was no statistically significant difference observed in the reduction of HDSS scores, hyperhidrosis area, and participant satisfaction between the axillae treated with LetiBTX-A and those treated with OnaBTX-A at 1, 3 and 6 months after injections. The median onset of action of both LetiBTX-A and OnaBTX-A were 2 ± 1 day (p = 0.317). Procedure-related pain was comparable between 2 formulations (P = 0.876). No serious adverse event was observed. This study concluded that LetiBTX-A and OnaBTX-A demonstrate comparable efficacy and safety profiles in treating primary axillary hyperhidrosis (PAH).

Fatal familial insomnia: A new case description with response to thoracic sympathetic nerve thermocoagulation and stellate ganglion block

Fatal familial insomnia (FFI) is a rare autosomal dominant neurodegenerative disorder characterized by rapidly progressive dementia, severe sleep disturbances, and autonomic dysfunction. The clinical manifestations of FFI can exhibit substantial variations, making it crucial to rule out other conditions, such as autoimmune encephalitis and Creutzfeldt-Jakob disease, during early diagnosis. In this study, we describe the case of a 58-year-old man who experienced persistent insomnia, autonomic symptoms, gait instability, and rapidly progressive dementia. Polysomnography revealed considerable alterations brain positron emission tomography/computed tomography showed no significant abnormal changes and cerebrospinal fluid analysis indicated a slight elevation in protein levels. Results of tests for autoimmune encephalitis antibodies were negative. The presence of the prion protein gene D178N mutation was confirmed through genetic testing and in conjunction with the patient's clinical manifestations, a diagnosis of FFI was established. Owing to severe autonomic neuropathy and intractable hyponatremia resulting from excessive sweating, therapeutic interventions, including thoracic sympathetic nerve thermocoagulation and stellate ganglion block, were attempted. These treatments initially led to symptomatic improvements, such as reduced sweating and amelioration of hyponatremia; however, sweating persisted, albeit to a lesser extent. Despite these interventions, the patient's condition deteriorated, leading to death 16 months after symptom onset owing to progressive agrypnia excitata, worsening dementia, and gait instability. This case underscores the current lack of effective treatments for FFI and highlights the urgent need for further research on this debilitating disorder.

Arabic Translation, Cultural Adaptation, and Validation of the Hyperhidrosis Disease Severity Scale (Ar-HDSS)

Background: Hyperhidrosis (HH) is characterized by excessive sweating, which affects quality of life. The Hyperhidrosis Disease Severity Scale (HDSS) is a four-point scale used to evaluate HH severity by measuring how much excessive sweating disrupts daily activities. This study aimed to translate, validate, and adapt the HDSS tool into Arabic. Methods: A quantitative, analytical, cross-sectional study was carried out from May to June 2024 on patients clinically diagnosed with HH. The process of translating the HDSS into Arabic involved three independent forward translations, followed by a preliminary version created by a reviewer. Three additional independent translators conducted backward translations. All of the versions were then revised and merged to produce the final version. Reliability was evaluated through a test-retest reliability approach to ensure the reproducibility of the results. For validity, we used construct validity to compare the HDSS with the HidroQoL index. Results: A total of 167 patients were included, with a mean age of 29 ± 9.02 years, and over half of the patients were male (61%). The interrater agreement between the HDSS test and the retest results was substantial, with a kappa coefficient of 0.732. Significant positive correlations were observed between the HDSS score and daily life (r = 0.413, p < 0.001), the psychological domain (r = 0.374, p < 0.001), and HidroQOL (r = 0.425, p < 0.001). Conclusions: Our findings demonstrate that the Arabic HDSS has excellent psychometric properties, including construct validity and reproducibility. Proper use of the Arabic HDSS will allow the effective assessment of HH severity.

The Creation of the Arabic Version of the Hyperhidrosis Quality of Life Index (HidroQoL©) with Validation and Cross-Cultural Adaptation

Purpose

Hyperhidrosis (HH) is characterized by excessive sweating, which can significantly affect quality of life. The Hyperhidrosis Quality of Life Index (HidroQoL©) is the latest tool that has been developed and validated for assessing the quality of life of patients with HH. Because of the absence of an Arabic version of the HidroQoL©, this research aimed to create, validate, and adapt the HidroQoL© into Arabic.

Patients and Methods

A quantitative, analytical, cross-sectional study was conducted with HH patients followed up in dermatology or thoracic surgery clinics. We assessed the results reliability through internal consistency and reproducibility by assessing test‒retest reliability. For validity, we conducted an exploratory factor analysis with an interitem correlation matrix and a rotated component matrix.

Results

A total of 167 participants were enrolled in this study; 61.1% were males, and 92.8% were Saudi. All 18 items of the HidroQoL©, including the daily life activities domain, psychosocial life domain, and whole HidroQoL©, had Cronbach's alpha values above 0.7. The test-retest reliability assessment demonstrated strong reproducibility. The correlations between each item and the other 17 items of the scale were positive, ranging between 0.2 and 0.6, and the results of the components analysis suggested that the questionnaire has three domains. The correlation between the test-retest results of the HidroQoL© revealed a significant strong positive correlation (r=0.9, P˂0.001).

Conclusion

Our findings revealed excellent psychometric properties of the Arabic HidroQoL© in terms of structural and construct validity, internal consistency, and reproducibility. Proper utilization of the Arabic HidroQoL© adequately assesses the quality of life of those affected by HH.

Evaluation of Efficacy and Safety of miraDry® Procedure in the Treatment of Primary Axillary Hyperhidrosis

INTRODUCTION

Primary axillary hyperhidrosis significantly impacts the quality of life of affected individuals. miraDry®, a non-invasive local precisely controlled thermal energy procedure, represents a promising treatment option. This retrospective analysis aimed to evaluate the treatment success and patient safety following miraDry® procedure in the treatment of primary axillary hyperhidrosis.

MATERIAL AND METHODS

A total of 139 patients receiving miraDry® procedure from 2019 to 2023 with miraDry® fresh protocol for treatment of excessive axillary hyperhidrosis were analyzed. Subjective assessment was performed before and after treatment using hyperhidrosis disease severity scale (HDSS). Minor test (iodine starch test) was done before treatment and 6 months after treatment to objectively quantify sweat severity. Patients with subjective or objective unsatisfied results after first procedure were scheduled for a second treatment.

RESULTS

The majority of treated patients (84%) could effectively be treated with one single treatment, while only 16% (n = 22) required a secondary intervention. HDSS after treatment completion (single and double treatment) showed a significant improvement (p < 0.001) in subjective evaluation of the treatment success. Minor tests demonstrated a significant reduction in sweat severity (p < 0.001), with 95% of patients experiencing no or minimal sweating after treatment completion. The miraDry® procedure demonstrated a favorable safety profile with typical and transient treatment reactions that mostly resolved within 6 months (94.2%) CONCLUSION: Our data demonstrate that miraDry® procedure is an effective and safe treatment option for primary axillary hyperhidrosis, which results in an immense improvement in quality of life and high satisfaction of affected individuals.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Comparing Compensatory Sweating After Video-Assisted Thoracoscopic Sympathectomy: (T2-3) Versus (T2-4) Levels for Treating Palmar Hyperhidrosis

INTRODUCTION

Primary hyperhidrosis is a disease that is characterized by excessive sweating beyond what is required to maintain the normal temperature of the body. Moreover, it has a great adverse effect on the life of the affected persons because of problems in their social lives. There are different modalities to treat primary hyperhidrosis, including medical and surgical treatment. However, in sympathectomy, there is still a lack of strong evidence regarding which level should be targeted to achieve maximum benefit with fewer complications.

METHODS

This prospective clinical study was conducted at the Cardiothoracic Surgery Department, Alexandria Main University Hospital, Alexandria, Egypt, from September 2021 to Jan 2022. The study involved a total of 50 eligible consecutive patients who had bilateral primary palmar hyperhidrosis managed by bilateral, bi-portal, and tubeless thoracoscopic approach with conventional general anesthesia. Group A represents 25 patients with 13 males (52%) who had sympathetic chain cutting at the level of T2-3, and group B represents 25 patients with 15 males (60%) who had sympathetic chain cutting at the level of T2-4. The effect on palmar hyperhidrosis, compensatory hyperhidrosis, and overall patient satisfaction was assessed on the Visual Analog Scale (VAS).

RESULT

Ninety-eight percent of patients in both groups showed postoperative complete dryness of the hand and improvement of their symptoms. There was a statistically significant (p<0.001) difference regarding the degree of severity of compensatory sweating post-operatively between both groups. In group A, 44% of patients had compensatory sweating, while in group B, 96% of patients had symptoms of compensatory sweating with varying degrees from 1 to 5 on a VAS-Score of five degrees.

CONCLUSION

The level of cauterization has no significant effect on palmar hyperhidrosis dryness after cutting the sympathetic chain at level (T2-3) vs. (T2-4). However, the greater the number of levels that are cauterized, which are three levels rather than two, the more severe the compensatory sweating in this study.

Comparative study of CT-guided radiofrequency and alcohol ablation in the treatment of primary hyperhidrosis

Objective

This study compared the efficacy and complications of percutaneous radiofrequency ablation with anhydrous alcohol ablation of sympathetic nerves in treating hyperhidrosis of the head and palms.

Methods

A retrospective analysis was conducted on 54 patients with primary hyperhidrosis in our department from June 2018 to June 2021, divided into a radiofrequency ablation group (30 cases) and an anhydrous alcohol ablation group (24 cases). Treatment outcomes were compared by analyzing the number of CT scans, effectiveness, and complications.

Results

In the radiofrequency group, symptoms of bilateral hyperhidrosis significantly improved in 24 patients, with an 80% postoperative satisfaction rate. In the alcohol ablation group, symptoms significantly improved in 19 patients postoperatively, with a 79.2% satisfaction rate. There was no statistically significant difference in effectiveness or complications between the two groups (all P > 0.05). The number of CT scans in the radiofrequency group was 4.60 ± 0.56 and 6.08 ± 0.28 in the alcohol group, showing a statistically significant difference (P < 0.05).

Conclusion

This study concluded that both percutaneous radiofrequency ablation and alcohol ablation are effective methods for hyperhidrosis treatment, with similar effectiveness and complication rates, but the radiofrequency ablation group required fewer CT scans.

The reliability and validity of a developed anxiety scale specific to primary focal hyperhidrosis symptoms

BACKGROUND

Patients with primary focal hyperhidrosis (hyperhidrosis) are known to have higher levels of anxiety induced by sweating than those who do not. However, in hyperhidrosis, no scale has been developed to measure anxiety specific to hyperhidrosis symptoms. Therefore, this study aimed to develop an anxiety scale specific to hyperhidrosis symptoms (ASSHS) and to verify its reliability and validity.

METHODS

Based on previous studies on hyperhidrosis and a preliminary survey conducted with 26 university students who met the diagnostic criteria for hyperhidrosis, 40 items that adequately reflected anxiety specific to hyperhidrosis symptoms were obtained. A survey was done to examine the internal consistency and validity of the our developed ASSHS. In total, 1,207 participants (680 male and 527 female; mean age ± standard deviation 18.7 ± 0.9 years) were included. A second survey (re-survey) was conducted three weeks later to verify the reliability. It included 201 participants (85 male and 116 female; mean age ± standard deviation 18.6 ± 0.7 years). The survey items included (1) the diagnostic criteria for hyperhidrosis, (2) our anxiety scale developed for primary focal hyperhidrosis symptoms (ASSHS), (3) Hyperhidrosis Disease Severity Scale (HDSS), (4) State-Trait Anxiety Inventory (STAI), (5) Hospital Anxiety and Depression Scale (HADS), (6) Dermatology Life Quality Index (DLQI), and (7) presence of anxiety induced by sweating.

RESULTS

The results of the factor analysis revealed 10 items with one factor, "anxiety specific to hyperhidrosis symptoms." The alpha coefficient of the ASSHS was α = 0.94. The correlation coefficient between the scores at re-test was r = 0.75. A moderate positive correlation was found between the ASSHS, HDSS (r = 0.53), and anxiety induced by sweating (r = 0.47) (all p < 0.001). Additionally, participants with hyperhidrosis symptoms had significantly higher ASSHS scores than did those without hyperhidrosis symptoms (p < 0.001). Those with mild/moderate hyperhidrosis and those with severe hyperhidrosis had significantly higher the ASSHS scores than did those without hyperhidrosis (p < 0.001).

CONCLUSIONS

This scale has sufficient reliability and validity as an instrument to measure anxiety specific to hyperhidrosis symptoms.

Efficacy and safety of radiofrequency ablation versus surgical sympathectomy in palmar hyperhidrosis

Radiofrequency ablation (RFA) comparative efficacy of treatments using video-assisted thoracoscopic sympathectomy (VATS) in the long term remains uncertain in patients with palmar hyperhidrosis (PHH). This study aimed to compare the efficacy and safety of RFA and VATS in patients with PHH. We recruited patients aged ≥ 14 years with diagnosed PHH from 14 centres in China. The treatment options of RFA or VATS were assigned to two cohort in patients with PHH. The primary outcome was the efficacy at 1-year. A total of 807 patients were enrolled. After propensity score matching, the rate of complete remission was lower in RFA group than VATS group (95% CI 0.21-0.57; p < 0.001). However, the rates of palmar dryness (95% CI 0.38-0.92; p = 0.020), postoperative pain (95% CI 0.13-0.33; p < 0.001), and surgery-related complications (95% CI 0.19-0.85; p = 0.020) were lower in RFA group than in VATS group, but skin temperature rise was more common in RFA group (95% CI 1.84-3.58; p < 0.001). RFA had a lower success rate than VATS for the complete remission of PHH. However, the symptom burden and cost are lower in patients undergoing RFA compared to those undergoing VATS.Trial Registration: ChiCTR2000039576, URL: http://www.chictr.org.cn/index.aspx .

Changes in electrodermal activity following sympathicotomy in hyperhidrosis patients

Objectives

The aim of this study was to assess the potential of electrodermal activity (EDA) as a diagnostic tool for preoperative evaluation in hyperhidrosis patients. EDA levels and patterns in different skin areas were investigated before and after endoscopic thoracic sympathicotomy (ETS) and was compared to healthy subjects.

Methods

Thirty-seven patients underwent two days of measurements before and after the operation. Twenty-five (67.5%) of the patients also had a third measurement after six months. Non-invasive EDA measurements, involving skin conductance, were sampled from five different skin areas while patients were at rest in supine and sitting positions or when subjected to stimuli such as deep inspirations, mental challenge, and exposure to a sudden loud sound.

Results

Prior to the operation, hyperhidrosis patients showed higher spontaneous palm EDA variations at rest and stronger responses to stimuli compared to healthy subjects. Patients with facial blushing/hyperhidrosis or combined facial/palmar hyperhidrosis showed minimal spontaneous activity or responses, particularly during mental challenge and sound stimulus. Notably, palm EDA response was abolished shortly following sympathicotomy, although a minor response was observed after six months. Minimal EDA responses were also observed in the back and abdomen postoperatively.

Conclusion

Hyperhidrosis patients showed stronger EDA response to stimuli compared to healthy subjects. Sympathicotomy resulted in the complete elimination of palm EDA responses, gradually returning to a limited extent after six months. These findings suggest that EDA recordings could be utilized in preoperative assessment of hyperhidrosis patients.

Longitudinal Assessment of Facial Hyperhidrosis Management: Evaluating the Utility and Quality of Life Improvements following Botulinum Toxin Injection

Facial hyperhidrosis is a debilitating condition that can severely impact the quality of life. This study aimed to assess the long-term utility of Botulinum toxin type A therapy (BTA) for facial hyperhidrosis and its impact on quality of life over a one-year period. Conducted at the Pius Brinzeu Clinical Emergency Hospital in Timisoara, Romania, this longitudinal observational study involved 77 adult patients with primary facial hyperhidrosis. Participants received two sessions of Botulinum toxin injections (50 U IncoBTX-A each) and were evaluated at baseline, 6 months, and 12 months using the Hyperhidrosis Disease Severity Scale (HDSS), WHOQOL-BREF, Dermatology Life Quality Index (DLQI), and a bespoke survey. The study demonstrated significant reductions in HDSS scores from 3.6 ± 0.5 to 1.2 ± 0.8 post-treatment, sustained at 1.3 ± 0.6 at 12 months (p-value < 0.001). DLQI scores markedly decreased from 24.8 ± 4.2 to 6.2 ± 2.1 post-treatment, stabilizing at 6.5 ± 2.5 at 12 months (p-value < 0.001). Sweat production significantly dropped from 0.75 g ± 0.15 to 0.18 g ± 0.07 per 15 min (p-value < 0.001). WHOQOL-BREF scores improved notably in the mental domain from 66.7 ± 6.1 to 70.8 ± 5.2 at 12 months (p-value < 0.001), with physical and social domains also showing significant improvements. Correlation analysis revealed strong negative correlations between DLQI total score and HDSS (rho = -0.72, p-value < 0.001) and sweat production (rho = -0.68, p-value < 0.001). Regression analysis indicated significant predictors for DLQI total score, including HDSS (B Coefficient = -3.8, p-value < 0.001) and sweat production (B Coefficient = -2.2, p-value < 0.001). BTA therapy significantly improved the quality of life in facial hyperhidrosis patients, with lasting effects on symptom severity, sweat production, and quality of life domains. The correlation and regression analyses further substantiated the treatment's impact on both physical and psychological aspects. These findings advocate Botulinum toxin as a viable long-term treatment for facial hyperhidrosis.

Pain Control during the Treatment of Primary Palmar Hyperhidrosis with Botulinum Toxin A by a Topical Application of Liposomal Lidocaine: Clinical Effectiveness

Primary palmar hyperhidrosis (PPH) constitutes a debilitating condition that profoundly impacts the social, functional, and occupational aspects of individuals. The intradermal administration of botulinum toxin type A (BoNT-A) stands as an established therapeutic approach for PPH, albeit one frequently accompanied by considerable pain, posing challenges for patient tolerance. Our study aimed to assess the efficacy of combining cryoanalgesia spray (CA) with topical anesthesia utilizing a cream containing liposomal lidocaine at a concentration of 40 mg/g, with the objective of mitigating the pain associated with intradermal BoNT-A injection for PPH treatment. Nineteen participants, aged ≥18 years and afflicted with severe PPH, were enrolled in a double-blind randomized vehicle-controlled trial. Patient-perceived pain during the procedure was quantified using the Numeric Rating Scale (NRS). Statistical analysis was applied to the collected data. The combination of CA and the topical application of liposomal lidocaine during BoNT-A treatment for PPH resulted in diminished pain compared to CA alone and the combination of CA with the application of a basic cream. Topical anesthesia through the application of a liposomal lidocaine-containing cream emerged as a facile, secure, and efficacious approach for alleviating the pain associated with intradermal BoNT-A injection in PPH treatment. Furthermore, it demonstrated compatibility with CA, thereby offering a comprehensive strategy for pain management during BoNT-A administration.

[Pharmacologic properties and results of a clinical study of oxybutynin hydrochloride lotion (APOHIDE® Lotion 20%) as a novel treatment for primary palmar hyperhidrosis]

APOHIDE® Lotion 20% is a topical agent for treating primary palmar hyperhidrosis that contains the active ingredient oxybutynin hydrochloride. Oxybutynin hydrochloride has anticholinergic effects and inhibits sweating by binding to the M3 receptor, a subtype of the muscarinic acetylcholine receptor, in eccrine sweat glands. The clinical response to oxybutynin hydrochloride treatment also involves N-desethyloxybutynin, an active metabolite of oxybutynin. A clinical study in Japanese patients with primary palmar hyperhidrosis showed superiority of APOHIDE® Lotion 20% over placebo, i.e., there were significantly more responders (i.e., patients with a reduction in sweat volume ≥50% from baseline) in the APOHIDE® Lotion 20% group (APOHIDE® Lotion 20% group: 52.8%, placebo group: 24.3%; treatment difference: 28.5%; P < 0.001, Fisher's exact test). This and other clinical studies reported some adverse events (AEs) associated with the drug's anticholinergic effects and some application site AEs, but most of the AEs were mild. Clinical response did not decrease with long-term (52-week) treatment, and only a few patients (2 of 125) discontinued treatment because of AEs. Taken together, study results indicate that APOHIDE® Lotion 20% may be an effective and safe new treatment option for patients with primary palmar hyperhidrosis.

Surprising Resolution of Life-Long Severe Generalized Hyperhidrosis Post-angioplasty and Stenting

Hyperhidrosis (HH) is a condition characterized by excessive sweating beyond thermoregulation needs. HH can be primary with no known etiology or secondary, as a symptom of underlying medical disease or a side effect of certain medications. Furthermore, HH can be focal, affecting one or a few body parts, or generalized, affecting the entire body. We present the case of a 49-year-old male with a history of primary generalized HH as well as coronary artery disease whose HH symptoms surprisingly resolved following coronary angioplasty and stenting. This unprecedented outcome of the procedure points to a potential association between HH and coronary artery disease, proposing potential management of HH through cardiovascular workup. In light of this result, we suggest that patients exhibiting generalized primary HH undergo a thorough comprehensive cardiovascular workup.

Reconstituted and frozen botulinum toxin A is as effective and safe as fresh for treating axillary hyperhidrosis: A retrospective study

The use of reconstituted and frozen left-over botulinum toxin A, for treatment of patients with axillary hyperhidrosis seems to be common practice in healthcare. Thus, the objective of this study was to investigate the efficacy and safety of frozen and thawed versus fresh reconstituted abobotulinum toxin (Dysport®) and onabotulinum toxin (Botox®) in the treatment of axillary hyperhidrosis. A retrospective study was conducted analysing efficacy and data from pre- and 24 weeks post-treatment questionnaires together with medical records of individuals with moderate to severe axillary hyperhidrosis. The patients had received fresh prepared botulinum toxin A in their right axilla while frozen and thawed botulinum toxin A had been administered in their left axilla. Treatment was conducted at our Hyperhidrosis Clinic, Umeå University Hospital, Sweden 2019-2021. Pre- and post-treatment questionnaires from 106 patients were analysed. The patients were 18 to 55 years old, with a mean age of 30.7 ± 9.9 years. No significant differences in patient-reported variables, Hyperhidrosis Disease Severity Scale and VAS 10-point scale, were found between the different preparations (frozen compared to fresh) for abobotulinum toxin and onabotulinum toxin, before treatment and at 6 months follow-up. Multivariable regression analysis resulted in no significant difference regarding side-effects between the preparations or brands of botulinum toxin. The findings of this study support our clinical experience that both abobotulinum toxin and onabotulinum toxin, reconstituted, frozen and thawed, seem to be as effective and safe as fresh prepared botulinum toxin when treating axillary hyperhidrosis. Our findings indicate that left-over preparations of abo- and onabotulinum toxins, stored and frozen for up to 6 months, is a cost-and time-effective way of handling botulinum toxin for treatment of axillary hyperhidrosis.

Compensatory Hyperhidrosis After Non-Surgical Treatment of Primary Focal Hyperhidrosis: Two-Year Single-Centered Prospective Study From Jordan

BACKGROUND

Primary focal hyperhidrosis (PH) can be managed by a wide range of medical and surgical modalities. Compensatory hyperhidrosis (CH) is a well-documented complication of surgical treatment. We aimed to investigate the occurrence of compensatory hyperhidrosis (CH) in PH patients after nonsurgical treatment with botulinum toxin A (BTX- A) or iontophoresis.

METHODOLOGY

We carried out a unicentric prospective study on PH patients from King Abdullah University Hospital (KAUH) in Jordan. PH patients were evaluated after 1-month of nonsurgical treatment. Patients who developed CH were re-assessed after 3-6 months through a telephone-based interview.

RESULTS

A total of 86 patients with PH who underwent nonsurgical treatment with iontophoresis or botulinum toxin were recruited. Twenty-four (27.9%) patients developed subjective CH. It was mild in (75%), moderate in (21%), and severe in (4%) of patients affected, it was self-limiting within a few months in all patients. Patients with CH did not differ significantly in demographic or clinical variables from patients who did not develop CH except at the site of PH (p value = .05).

CONCLUSION

The findings of this study indicate that more than quarter (27.9%) of patients with PH may develop minor compensatory sweating, however this didn't affect satisfaction with treatment.

Long-term evaluation of the safety and efficacy of a novel 20% oxybutynin hydrochloride lotion for primary palmar hyperhidrosis: An open-label extension study

The long-term safety and efficacy of 52-week application of oxybutynin hydrochloride 20% lotion (20% OL) for the treatment of primary palmar hyperhidrosis (PPHH) in Japanese patients aged ≥12 years were evaluated in an open-label extension (OLE) of a 4-week, randomized, double-blind (DB) study. The OLE included 114 patients who completed the DB study and wished to continue treatment and 12 new patients. In the safety analysis population (125 patients), the incidence of adverse events (AEs) and adverse drug reactions (ADRs) was 79.2% and 36.0%, respectively. Serious AEs were observed in two patients but were considered unrelated to the investigational drug. The incidence of AEs that led to study discontinuation was 1.6%. The incidence of application site AEs and ADRs was 35.2% and 26.4%, respectively. The severity of most events was mild. The incidence of anticholinergic AEs related to dry mouth was 3.2% for thirst and 0.8% for dry throat. The long-term efficacy of 20% OL was confirmed by a long-lasting reduction in sweat volume and improvement in the Hyperhidrosis Disease Severity Scale and Dermatology Life Quality Index. This study has several limitations: First the results may include some bias because most of the participants were from the prior DB study; second, the results may not be generalizable because only a few participants were in the age group most susceptible to PPHH (i.e., < 15 years old); and third, the study did not obtain safety information from treatment for more than 52 weeks, so this information must be collected in clinical practice in the future. No reduced therapeutic effect was observed in patients with PPHH in this study after 52-week application of 20% OL. Also, few patients experienced serious AEs or AEs that led to study treatment discontinuation.

Safety and efficacy of oxybutynin in patients with hyperhidrosis: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Sweating is a physiologic mechanism of human thermoregulation. Hyperhidrosis is defined as a somatic disorder where the sweating is exaggerated in an exact area because the sweat glands are hyperfunctioning. It negatively affects the quality of life of the patients. We aim to investigate patient satisfaction and the effectiveness of oxybutynin in treating hyperhidrosis.

METHODS

We prospectively registered the protocol of this systematic review and meta-analysis on PROSPERO (CRD 42022342667). This systematic review and meta-analysis were reported according to the PRISMA statement guidelines. We searched three electronic databases (PubMed, Scopus, Web of Science) from inception until June 2, 2022, using MeSH terms. We include studies comparing patients with hyperhidrosis who received oxybutynin or a placebo. We assessed the risk of bias using the Cochrane risk of bias assessment tool (ROB2) for randomized controlled trials. The risk ratio was calculated for categorical variables, and the mean difference was calculated for continuous variables using the random effect model with 95% confidence intervals (CI).

RESULTS

Six studies were included in the meta-analysis, with a total of 293 patients. In all studies, patients were assigned to receive either Oxybutynin or Placebo. Oxybutynin represented an HDSS improvement (RR = 1.68 95% CI [1.21, 2.33], p = 0.002). It also can improve the quality of life. There is no difference between oxybutynin and placebo regarding dry mouth (RR = 1.68 95% CI [1.21, 2.33], p = 0.002).

CONCLUSION

Our study suggests that using oxybutynin as a treatment for hyperhidrosis is significant and needs to be highlighted for clinicians. However, more clinical trials are needed to grasp the optimum benefit.

Hyperhidrosis: A targeted literature review of the disease burden

Hyperhidrosis is a chronic skin condition characterized by excessive sweating. It poses a burden on affected people, reducing their quality of life and productivity. We undertook a targeted literature review (TLR) to gather current evidence on the epidemiology as well as the human and economic burden posed on patients with hyperhidrosis. Searches were performed in Medline database (access via OVID interface) and ICHUSHI database. Articles published between January 2000 and September 2020 that analyzed at least 50 patients were included. Sixty-four publications were identified and 38 publications covering a unique domain were selected to inform this TLR. The incidence of hyperhidrosis ranged from 0.13% in the UK to 0.28% in the USA, with a higher rate in females. The prevalence of hyperhidrosis varied from 2.8%-4.8% in the US general population to 18.40% in Chinese inpatients, while the prevalence of axillary hyperhidrosis varied from 1.4% in the US general population to 5.75% in Japanese employees/students. Due to excessive sweating, hyperhidrosis was reported to be a moderate-to-extreme limitation at work for the US patients, with 33.5% feeling unhappy. Patients' satisfaction was high post-treatment. Considerable costs were related to the treatment with botulinum toxin and surgery. Hospital stays for surgery lasted from 10 h to 3 days. The percentage of patients who sought a medical consultation varied from 6.3% for Japanese patients with primary focal hyperhidrosis to 51% for the US general population with any type of hyperhidrosis. There is limited evidence of the hyperhidrosis burden, particularly among Japanese patients; however, the burden was high and limited patients' daily functioning. Future actions should include implementation of educational programs to raise awareness of the condition, conduct of larger studies, and generation of more evidence. Understanding the nature of hyperhidrosis and the burden it poses is of utmost importance.

Predictors of Compensatory Sweating Following Video-Assisted Thoracoscopic Sympathectomy in Primary Palmar Hyperhidrosis

BACKGROUND

Compensatory sweating (CS) is a frequent health concern following treatment of palmar hyperhidrosis using video-assisted thoracoscopic sympathectomy (VATS) and can reduce level of patient satisfaction.

METHODS

A retrospective cohort study including consecutive patients who underwent VATS for primary palmar hyperhidrosis (HH) over a 5-year period was conducted. Various demographic, clinical, and surgical variables were tested for their correlation to postoperative CS through univariate analyses. Variables with significant correlation to outcome were included in a multivariable logistic regression for determining significant predictors.

RESULTS

The study included 194, predominantly male (53.6%), patients. About 46% of patients developed CS, mostly during the first month after VATS. Variables with significant correlation (P < 0.05) to CS included age (20 ± 3.6 years), body mass index (BMI) (mean 27 ± 4.9), smoking (34%), associated plantar HH (50%), and laterality of VATS (40.2% in dominant side). Only level of activity showed a statistical trend (P = 0.055). In multivariable logistic regression, BMI, plantar HH, and unilateral VATS were significant predictors for CS. Using receiver operating characteristic curve, the best cutoff point of BMI for prediction was 28.5, with sensitivity 77% and specificity 82%.

CONCLUSIONS

CS is a frequent health concern early after VATS. Patients with BMI >28.5 and no plantar HH are at higher risk of postoperative CS, and a unilateral dominant side VATS as an initial management step may lessen the risk of CS. Bilateral VATS can be provided for patients with low risk of CS and patients with low satisfaction after unilateral VATS.

Treatment of hyperhidrosis with Botox (onabotulinumtoxinA): Development, insights, and impact

Hyperhidrosis (chronic excessive sweating) may substantially affect an individual's emotional and social well-being. Therapies available before onabotulinumtoxinA were generally topical, with limited effectiveness, application-site skin reactions, and frequent, time-consuming treatments. Intradermal injection of onabotulinumtoxinA to treat sweat glands arose as a novel therapeutic approach. To develop this treatment, appropriate dosing needed to be established, and training on administration was required. Further, no previous scale existed to measure the effects of hyperhidrosis on patients' lives, leading Allergan to develop and validate the 4-point Hyperhidrosis Disease Severity Scale (HDSS), which measures the disease's impact on daily activities. The onabotulinumtoxinA clinical development program for hyperhidrosis included 2 double-blind, placebo-controlled pivotal trials, immunogenicity studies, long-term studies of safety and efficacy, and quality of life assessments. In Europe and North America, the primary efficacy measures were, respectively, axillary sweat production measured gravimetrically and HDSS improvement. Compared with placebo, onabotulinumtoxinA treatment significantly reduced axillary sweat production and axillary hyperhidrosis severity, as measured by a 2-point or greater reduction on the HDSS. The effects of onabotulinumtoxinA occurred rapidly, within 1 week after injection, and lasted ≥6 months. Treatment with onabotulinumtoxinA was associated with significant quality of life improvements based on Short Form-12 physical and mental component scores. The Hyperhidrosis Impact Questionnaire also indicated greater treatment satisfaction, reduced negative impact on aspects of daily life, and improved emotional well-being with onabotulinumtoxinA versus placebo. The clinical development program and subsequent clinical experience showed that onabotulinumtoxinA treatment for hyperhidrosis was well tolerated with no new safety signals, and led to greater disease awareness.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

A novel lotion formulation of 20% oxybutynin hydrochloride for the treatment of primary palmar hyperhidrosis: A randomized, placebo-controlled, double-blind, phase III study

BACKGROUND

No previous controlled studies have been specifically designed or adequately powered to show the efficacy of topical oxybutynin for palmar hyperhidrosis by using quantitative measures.

OBJECTIVE

To evaluate efficacy of 20% oxybutynin hydrochloride lotion (20% OL) in reducing palmar sweat volume in patients with primary palmar hyperhidrosis (PPHH).

METHODS

In a randomized controlled trial, Japanese patients with PPHH aged 12 years and older received either 20% OL (n = 144) or placebo (n = 140) on both palms once daily for 4 weeks. Palmar sweat volume was measured by the ventilated capsule method. For the primary outcome, response was defined as a reduction of sweat volume of at least 50% from baseline.

RESULTS

At week 4, the responder rate for sweat volume was significantly higher in the 20% OL arm than in the placebo arm (52.8% vs 24.3%, respectively; treatment difference, 28.5% [95% CI, 17.7% to 39.3%]; P < .001). No serious adverse events occurred, and no adverse events led to treatment discontinuation.

LIMITATIONS

The treatment period was only 4 weeks.

CONCLUSIONS

In patients with PPHH, 20% OL is superior to placebo in reducing palmar sweat volume.

Adverse Events of Light-Assisted Hair Removal: An Updated Review

BACKGROUND

With light-assisted hair removal becoming widely used, reports of adverse effects are increasing.

OBJECTIVE

To review all the reported optical incidents and cutaneous complications of laser or intense pulse light-assisted hair removal.

METHODS

A PubMed database systematic search was performed to identify studies reporting such adverse events before July 2022 using the Mesh terms "adverse effects" AND "hair removal" AND ("laser" OR "intense pulse light").

RESULTS

Altogether, 358 references were identified. After excluding duplicates, unrelated articles, guidelines, and conference abstracts, then adding references from studies bibliography, 104 publications were included. Ocular incidents consisted of anterior uveitis, iritis and iris atrophy, pupillary distortion, posterior synechiae, anterior chamber pigment, and cataracts in the anterior subcapsular region. Cutaneous complications consisted of pain, burns, folliculitis, leukotrichia, paradoxical hypertrichosis, pigmentary changes, changes in nevi, pili bigemini, herpes infection, hyperhidrosis, bromhidrosis, Fox-Fordyce disease, and frostbite from the cooling system. They were mostly correlated to skin type and body area as well as to light device and set parameters. Intense pulse light devices were found to be less painful than alexandrite laser, yet more painful than diode laser; Nd:YAG laser had the highest pain score.

CONCLUSION

Optical incidents can be systematically avoided. Cutaneous complications are usually related to professional errors and patient characteristics. Better knowledge of laser physics and adequate training of laser operators are key recommendations to avoid undesirable side effects. Safety recommendations help prevent most of the reported complications.

Hyperhidrosis quality of life index (HidroQoL): further validation by applying classical test theory and item response theory using data from a phase III clinical trial

BACKGROUND

The Hyperhidrosis Quality of Life Index (HidroQoL ©) is a well-developed and validated patient-reported outcome measure assessing the quality-of-life impacts in hyperhidrosis with 18 items. Our aim was to extend the already existing validity evidence for the HidroQoL, especially in relation to structural validity. Especially Rasch analysis has not been applied to the final 18-item HidroQoL before.

METHODS

Data from a phase III clinical trial were used. Confirmatory factor analysis was conducted to confirm the two a priori HidroQoL scales within classical test theory. Furthermore, the assumptions of the Rasch model (model fit, monotonicity, unidimensionality, local independence) and Differential Item Functioning (DIF) were assessed using item response theory.

RESULTS

The sample included 529 patients with severe primary axillary hyperhidrosis. The two-factor structure could be confirmed by the confirmatory factor analysis (SRMR = 0.058). The item characteristic curves showed mainly optimally functioning response categories, indicating monotonicity. The overall fit to the Rasch model was adequate and unidimensionality for the HidroQoL overall scale could be confirmed, since the first factor had an eigenvalue of 2.244 and accounted for 18.7%. Local independence was below assumed thresholds (residual correlations ≤ 0.26). DIF analysis, controlling for age or gender, was critical for four and three items, respectively. However, this DIF could be explained.

CONCLUSION

Using classical test theory and item response theory/Rasch analyses, this study provided further evidence for the structural validity of the HidroQoL. This study confirmed several specific (measurement) properties of the HidroQoL questionnaire in patients with physician-confirmed severe primary axillary hyperhidrosis: the HidroQoL is a unidimensional scale allowing the summation of scores to generate a single score, and simultaneously it has a dual structure, also allowing the calculation of separate domain scores for daily activities and psychosocial impacts. With this study, we provided new evidence of the structural validity of the HidroQoL in the context of a clinical trial. Trial registration The study was registered (ClinicalTrials.gov identifier: NCT03658616, 05 September 2018, https://clinicaltrials.gov/ct2/show/NCT03658616?term=NCT03658616&draw=2&rank=1 ).

Evaluation of quality of life (QOL) of young patients with primary hyperhidrosis (PH) before and after endoscopic thoracic sympathectomy (ETS)

BACKGROUND

Primary hyperhidrosis (PH) affects young patients and may cause emotional distress and a negative quality of life (QOL).

OBJECTIVE

We sought to evaluate the QOL of children and adolescents with PH treated by endoscopic thoracic sympathectomy.

METHODS

A study of 220 patients was performed, based on submitted QOL questionnaires from their first consultation. Patients were evaluated within 1 week and 24 months after surgery.

RESULTS

Before endoscopic thoracic sympathectomy, the QOL in relation to PH was declared very poor by 141 patients, and poor by the remaining 79 (P = .552). Postoperative cure was reported in 100% of palmar and axillary PH cases, and in 91.7% of facial PH. After 24 months, the QOL was described as much better by 212 patients, a little better by 6 patients, and 2 patients reported no change.

LIMITATIONS

Convenience sampling was used and patients were taken from private practice only, raising the possibility of bias in gathering the data.

CONCLUSION

Onset of PH symptoms was mainly before the age of 10 years and substantially affected daily activities. Endoscopic thoracic sympathectomy cured PH and promoted significant improvement in the QOL of these young patients.

Comparison of the efficacy of ETS with different segments for palmar, axillary and plantar hyperhidrosis

BACKGROUND

To compare the near and long-term outcomes of endoscopic thoracic sympathectomy (ETS) for palmar, axillary and plantar hyperhidrosis.

METHODS

We retrospectively analyzed the clinical data of 218 patients with hyperhidrosis who were admitted to the Department of Thoracic Surgery of Gansu Provincial People's Hospital for surgical treatment from April 2014 to August 2021. The patients were divided into three groups according to the method of ETS and the perioperative clinical data and postoperative follow-up data were collected to compare the near and long term outcomes of the three groups.

RESULTS

There were 197 eligible patients at follow-up, 60 patients in the R4 cut-off group, 95 patients in the R3 + R4 cut-off group and 42 patients in the R4 + R5 cut-off group. There were no statistically significant differences in baseline indicators such as sex, age and positive family history among the three groups (P > 0.05). There was no statistically significant difference between the three groups in terms of operative time (P = 0.148), intraoperative bleeding (P = 0.308) and postoperative hospital stay (P = 0.407). Postoperatively, all three groups showed significant relief of palmar hyperhidrosis symptoms, with the R3 + R4 group having an advantage in terms of relief of axillary hyperhidrosis symptoms, patient satisfaction and quality of life index at 6 months postoperatively and the R4 + R5 group having an advantage in terms of relief of plantar hyperhidrosis symptoms. The difference in compensatory hyperhidrosis at 12 months postoperatively was not statistically significant among the three groups (P = 0.867), but the incidence was higher in the R3 + R4 and R4 + R5 groups than that in the R4 group.

CONCLUSION

Patients with simple palmar hyperhidrosis can first consider R4 cut-off treatment; R3 + R4 cut-off is more effective in treating palmar hyperhidrosis combined with axillary hyperhidrosis; R4 + R5 cut-off is more effective in treating palmar hyperhidrosis combined with plantar hyperhidrosis. However, patients need to be informed that R3 + R4 and R4 + R5 dissection may increase the risk of severe compensatory hyperhidrosis after surgery.

Questionnaire-based epidemiological survey of primary focal hyperhidrosis and survey on current medical management of primary axillary hyperhidrosis in Japan

To obtain current epidemiological information on primary focal hyperhidrosis in Japan, a large epidemiological survey was conducted using a web-based questionnaire. The prevalence of primary focal hyperhidrosis was 10.0% and the site-specific prevalence was highest for primary axillary hyperhidrosis (5.9%). The proportion of respondents with primary focal hyperhidrosis who had consulted a physician was 4.6%, which was similar to the low prevalence reported previously in 2013 in Japan. A questionnaire survey for physicians and individuals with primary axillary hyperhidrosis on the current medical management of primary axillary hyperhidrosis showed that physicians recognized the existence of patients who were very worried about hyperhidrosis, but failed to provide active treatment. Regarding the information provided by patients to physicians at presentation, it was found that patients failed to provide sufficient information to the physicians about their worries in daily life. Among individuals who had sought medical care with primary axillary hyperhidrosis, 62.3% reported that they were not currently receiving treatment, highlighting a challenge to be addressed regarding continued treatment. Frequently chosen options leading to willingness to receive treatment were less expensive treatment and highly effective treatment as well as feeling free to consult a physician, suggesting a desire for an improved medical environment.

Association of primary focal hyperhidrosis with anxiety induced by sweating: A cross-sectional study of Japanese university students focusing on the severity of hyperhidrosis and site of sweating

Hyperhidrosis significantly reduces patients' quality of life, with many reporting feeling highly anxious. However, the relationship between hyperhidrosis and anxiety induced by sweating has not been examined in detail. The current study examined the relationship between: (1) the presence of hyperhidrosis symptoms, (2) hyperhidrosis severity, and (3) the sites of the most sweating and anxiety induced by sweating. A cross-sectional web-based survey was conducted among university students, and 1080 consenting participants (600 males and 480 females; mean age, 18.8 years) were included in the analysis. The survey items were: (1) diagnostic criteria for hyperhidrosis, (2) Hyperhidrosis Disease Severity Scale, (3) presence of anxiety induced by sweating, and (4) site of the most sweating. The results of multiple logistic regression analysis adjusted for sex and age showed that the odds ratio (OR) for anxiety induced by sweating was significantly higher in participants who screened positive for hyperhidrosis than in those who screened negative (OR, 9.72 [95% CI, 5.80-16.27]). The OR of anxiety induced by sweating was 7.11 (95% CI, 3.99-12.65) for mild/moderate hyperhidrosis and 23.46 (95% CI, 7.15-76.93) for severe hyperhidrosis, compared with those who screened negative for hyperhidrosis. Compared with those who screened negative for hyperhidrosis, the OR for anxiety induced by sweating in those with the palmar, plantar, axillary, and head/face as the site of the most sweating was 7.74 (95% CI, 3.91-15.33), 14.86 (95% CI, 1.83-120.58), 16.92 (95% CI, 5.95-48.14), and 5.38 (95% CI, 1.39-20.74), respectively. Our findings suggest that participants who screened positive for hyperhidrosis, mild/moderate or severe, are at a higher risk of anxiety induced by sweating than participants who screened negative for hyperhidrosis.

Pharmacovigilance-based drug repurposing: searching for putative drugs with hypohidrosis or anhidrosis adverse events for use against hyperhidrosis

BACKGROUND

Drug repurposing refers to the application of existing drugs to new therapeutic indications. As phenotypic indicators of human drug response, drug side effects may provide direct signals and unique opportunities for drug repurposing.

OBJECTIVES

We aimed to identify drugs frequently associated with hypohidrosis or anhidrosis adverse reactions (that is, the opposite condition of hyperhidrosis) from the pharmacovigilance database, which could be potential candidates as anti-hyperhidrosis treatment agents.

METHODS

In this observational, retrospective, pharmacovigilance study, adverse event reports of hypohidrosis or anhidrosis in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) were assessed between January 2004 and December 2021 using reporting odds ratio (ROR) estimates and categorized by the World Health Organization Anatomical Therapeutic Chemical (ATC) classification code. The onset time of drug-associated hypohidrosis or anhidrosis was also examined.

RESULTS

There were 540 reports of 192 drugs with suspected drug-associated hypohidrosis or anhidrosis in the FAERS database, of which 39 drugs were found to have statistically significant signals. Nervous system drugs were most frequently reported (187 cases, 55.82%), followed by alimentary tract and metabolism drugs (35 cases, 10.45%), genitourinary system and sex hormones (28 cases, 8.36%), and dermatologicals (22 cases, 6.57%). The top 3 drug subclasses were antiepileptics, drugs for urinary frequency and incontinence, and antidepressants. Taking disproportionality signals, pharmacological characteristics of drugs and appropriate onset time into consideration, the main putative drugs for hyperhidrosis were glycopyrronium, solifenacin, oxybutynin, and botulinum toxin type A. Other drugs, such as topiramate, zonisamide, agalsidase beta, finasteride, metformin, lamotrigine, citalopram, ciprofloxacin, bupropion, duloxetine, aripiprazole, prednisolone, and risperidone need more investigation.

CONCLUSIONS

Several candidate agents among hypohidrosis or anhidrosis-related drugs were identified that may be redirected for diminishing sweat production. There are affirmative data for some candidate drugs, and the remaining proposed candidate drugs without already known sweat reduction mechanisms of action should be further explored.

Hyperhidrosis in sleep disorders - A narrative review of mechanisms and clinical significance

Hyperhidrosis is characterized by excessive sweating beyond thermoregulatory needs that affects patients' quality of life. It results from an excessive stimulation of eccrine sweat glands in the skin by the sympathetic nervous system. Hyperhidrosis may be primary or secondary to an underlying cause. Nocturnal hyperhidrosis is associated with different sleep disorders, such as obstructive sleep apnea, insomnia, restless legs syndrome/periodic limb movement during sleep and narcolepsy. The major cause of the hyperhidrosis is sympathetic overactivity and, in the case of narcolepsy type 1, orexin deficiency may also contribute. In this narrative review, we will provide an outline of the possible mechanisms underlying sudomotor dysfunction and the resulting nocturnal hyperhidrosis in these different sleep disorders and explore its clinical relevance.

Nationwide Cross-sectional Analysis of Endoscopic Thoracic Sympathectomy to Treat Hyperhidrosis Over 12 years in Brazil: Epidemiology, Costs, and Mortality

OBJECTIVE

To analyze the number of endoscopic thoracic sympathectomies performed to treat hyperhidrosis in the Universal Public Health System of Brazil, the government reimbursements, and the in-hospital mortality rates.

BACKGROUND

Even though endoscopic thoracic sympathectomy has been widely performed for the definitive treatment of hyperhidrosis, no series reported mortality and there are no population-based studies evaluating its costs or its mortality rate.

METHODS

Data referring to endoscopic thoracic sympathectomy to treat hyperhidrosis between 2008 and 2019 were extracted from the database of the Brazilian Public Health System, which insures more than 160 million inhabitants.

RESULTS

Thirteen thousand two hundred one endoscopic thoracic sympathectomies to treat hyperhidrosis were performed from 2008 to 2019, with a rate of 68.44 procedures per 10 million inhabitants per year. There were 6 in-hospital deaths during the whole period, representing a mortality rate of 0.045%. The total expended throughout the years was U$ 6,767,825.14, with an average of U$ 512.68 per patient.

CONCLUSIONS

We observed a rate of 68.44 thoracoscopic sympathectomies for hyperhidrosis' treatment per 10 million inhabitants per year. The inhospital mortality rate was very low, 0.045%, though not nil. To our knowledge, no published series is larger than ours and we are the first authors to formally report deaths after endoscopic thoracic sympathectomies to treat hyperhidrosis. Moreover, there is no other population-based study addressing costs and mortality rates of every endoscopic thoracic sympathectomy for the treatment of any site of hyperhidrosis in a given period.

Hyperhidrosis: A Central Nervous Dysfunction of Sweat Secretion

Hyperhidrosis (HH) is a central nervous dysfunction characterized by abnormally increased sweating due to a central dysregulation of sweat secretion. HH significantly affects the quality of life of patients in their private, social and professional environments. Physiologically, sweating is a mechanism that regulates body temperature, but it may also be triggered by emotional or gustatory stimuli. There are two main types of sweat glands: eccrine and apocrine glands. The central nervous system controls sweat secretion through the release of neurotransmitters into the autonomous nervous system (ANS) that activate the sweat glands. The hypothalamus has two separate neuronal pathways, one for thermoregulation and one for emotions. HH may thus be due to either a neuronal dysfunction of ANS regulation leading to a hyperactivity of the sympathetic nervous system, or to abnormal central processing of emotions. Crucially, there is no dysfunction of the sweat glands themselves. Various pathogenic mechanisms have been proposed to be involved in pathological sweat secretion in HH, ranging from structural changes within the ANS to increased expression of aquaporin 5 and upregulation of activin A receptor type 1 in eccrine sweat glands. Although a genetic predisposition has been demonstrated, it remains unclear exactly which genes are involved. To identify new, potential therapeutic targets and to improve treatment options, a good understanding of the signaling pathways involved, the underlying mechanisms, and the genetic components is essential. In this review we discuss the various aspects of sweat physiology and function that are necessary to explain pathological sweating. Our aim is to raise awareness of the complexity of HH to promote a better understanding of the disorder.

When to investigate for secondary hyperhidrosis: data from a retrospective cohort of all causes of recurrent sweating

Background: Identification of underlying diseases is crucial for secondary hyperhidrosis management, but data are lacking to guide appropriate investigation.Objective: To describe aetiologies of recurrent sweating in a hospital setting and the diagnostic performance parameters of their respective clinical/biological features.Patients and Methods: We performed a monocentric evaluative study in a tertiary care centre. Patients with recurrent generalised sweating were selected via the Clinical Data Warehouse (CDW) by screening all electronic hospital documents from the year 2018 using a keyword-based algorithm. All in and out-patients aged ≥ 18 years having reported recurrent sweating for at least 2 weeks in 2018 were included, with a minimum one-year follow-up after symptoms' onset.Results: A total of 420 patients were included. Over 130 different aetiologies were identified; 70 patients (16.7%) remained without diagnosis. Solid organ cancers (14.3% with 13 lung cancers), haematologic malignancies (14.0% with 35 non-Hodgkin's lymphomas) and Infectious Diseases (10.5% including 13 tuberculosis) were the most frequent diagnoses. Other aetiologies were gathered into inflammatory (16.9%) and non-inflammatory (27.6%) conditions. To distinguish non-inflammatory and undiagnosed hyperhidrosis from other causes, fever had a specificity of 94%, impaired general condition a sensitivity of 78%, and C-reactive protein (CRP) > 5.6 mg/l a positive predictive value of 0.86. Symptoms' duration over 1 year was in favour of non-infectious and non-malignant causes (94% specificity).Conclusions: We identified fever, impaired general condition, duration, and CRP as helpful orientation parameters to assess the need for complementary explorations for hyperhidrosis. The study provides a diagnostic algorithm for the investigation of recurrent sweating.KEY MESSAGESIn a hospital setting, malignancies and infections are the most frequently associated diseases, but 1/5 remain without diagnosis.Fever is a specific but not sensitive sign to distinguish inflammatory conditions.Over 1 year duration of symptoms significantly reduce the probability of malignancy or infection as the underlying diagnosis.

Population-based analysis of the epidemiology of the surgical correction of hyperhidrosis in 1,216 patients over 11 years: a cross-sectional study

BACKGROUND

Endoscopic thoracic sympathectomy is the definitive surgical treatment for hyperhidrosis and a nationwide study has suggested that cultural and socioeconomic factors play a role in the numbers of operations performed. Thus, there is a need to evaluate local data in order to understand the local epidemiology and trends in hyperhidrosis treatment.

OBJECTIVE

To study the epidemiology of sympathectomy for treating hyperhidrosis in São Paulo, the largest city in Brazil.

DESIGN AND SETTING

Population-based retrospective cross-sectional study.

METHODS

Data on sympathectomies for treating hyperhidrosis between 2008 and 2018 were assessed from the database of the Municipal Health Department of São Paulo, Brazil.

RESULTS

65.29% of the patients were female, 66.2% were aged between 20 and 39 years and 37.59% had registered with addresses outside São Paulo. 1,216 procedures were performed in the city of São Paulo from 2008 to 2018, and 78.45% of them were in only two public hospitals. The number of procedures significantly declined over the years (P = 0.001). 71.63% of the procedures were associated with 2-3 days of hospital stay, only 78 intensive care unit days were billed and we did not observe any intra-hospital death.

CONCLUSION

The profile of patients operated on in São Paulo (young women) is similar to that described in other populations. Sympathectomy is a very safe procedure, with no mortality in our series. There was a decreasing trend in the number of surgeries over the years.

An online survey of pelvic congestion support group members regarding comorbid symptoms and syndromes

Objectives

Patients with pelvic congestion syndrome (PCS) often report overlapping somatic symptoms and syndromes. The objective of this study was to explore the prevalence of co-existing symptoms and self-reported syndrome diagnoses among women with PCS and to inform future research hypotheses.

Methods

A brief online survey was offered to members of a PCS support group website. Responses were assessed for self-reported co-existing symptoms and formal diagnoses, including: chronic fatigue syndrome, fibromyalgia, postural tachycardia syndrome, irritable bowel syndrome, migraines, interstitial cystitis, and temporomandibular joint dysfunction.

Results

Of a total of 6000 members, there were 398 respondents; 232 (59%) had not yet been treated for PCS. Among these, the most prevalent co-existing symptoms were as follows: severe fatigue (72%), dizziness (63%), IBS symptoms (61%), brain fog (33%), migraines (49%), polyuria or dysuria (41%), excessive sweating (31%), TMJ pain (31%), and loose skin or lax joints (18%). These are much higher than reported for the general female population. The most commonly self-reported comorbid syndrome diagnoses for the overall group of 398 were: irritable bowel syndrome (29%), fibromyalgia (13%), spinal nerve problems (18%), interstitial cystitis (10%), postural tachycardia syndrome (9%), hypertension (11%), chronic fatigue syndrome (10%), and Ehlers-Danlos syndrome (6%). Other than with hypertension, these rates are variably higher than in the general population.

Conclusion

Several self-reported co-existing symptoms and syndromes are more prevalent in members of a PCS support group relative to the reported prevalence in the general population. More formal investigation is warranted to evaluate this finding and to investigate potential etiologic links. Ehlers-Danlos Syndrome appears to be common in self identifying PCS women.

Real sweating in a virtual stress environment: Investigation of the stress reactivity in people with primary focal hyperhidrosis

Background

Hyperhidrosis (excessive sweating, OMIM %114110) is a complex disorder with multifactorial causes. Emotional strains and social stress increase symptoms and lead to a vicious circle. Previously, we showed significantly higher depression scores, and normal cortisol awakening responses in patients with primary focal hyperhidrosis (PFH). Stress reactivity in response to a (virtual) Trier Social Stress Test (TSST-VR) has not been studied so far. Therefore, we measured sweat secretion, salivary cortisol and alpha amylase (sAA) concentrations, and subjective stress ratings in affected and non-affected subjects in response to a TSST-VR.

Method

In this pilot study, we conducted TSST-VRs and performed general linear models with repeated measurements for salivary cortisol and sAA levels, heart rate, axillary sweat and subjective stress ratings for two groups (diagnosed PFH (n = 11), healthy controls (n = 16)).

Results

PFH patients showed significantly heightened sweat secretion over time compared to controls (p = 0.006), with highest quantities during the TSST-VR. In both groups, sweating (p < 0.001), maximum cortisol levels (p = 0.002), feelings of stress (p < 0.001), and heart rate (p < 0.001) but not sAA (p = 0.068) increased significantly in response to the TSST-VR. However, no differences were detected in subjective ratings, cortisol concentrations and heart rate between PFH patients and controls (p_all > 0.131).

Conclusion

Patients with diagnosed PFH showed stress-induced higher sweat secretion compared to healthy controls but did not differ in the stress reactivity with regard to endocrine or subjective markers. This pilot study is in need of replication to elucidate the role of the sympathetic nervous system as a potential pathway involved in the stress-induced emotional sweating of PFH patients.

Chinese expert consensus on the surgical treatment of primary palmar hyperhidrosis (2021 version)

Primary palmar hyperhidrosis (PPH) is a pathologic condition of excessive sweating on hands that has adverse impacts on patients’ social activity, professional life, and psychological state. Endoscopic thoracic sympathicotomy (ETS) is by far the treatment choice for PPH with the most stable and durable curative effects, but special attention should be given to the side effects of the surgery, especially compensatory hyperhidrosis (CH). This consensus is the second version of the Chinese Expert Consensus on the Surgical Treatment of PPH by the China Expert Committee on Palmar Hyperhidrosis (CECPH), which was published 10 years ago. This consensus emphasizes the need for special attention and careful assessment of the patients’ feelings, as well as their emotional and mental state, and emphasizes that distress due to palmar sweating and the desire for treatment are prerequisites for diagnosis. It also provides a more nuanced delineation of CH and reviews all new attempts to prevent and treat this side effect. New evidence of the epidemiology, pathogenesis of PPH, and indications for surgery were also assessed or recommended.

THE PHARMACOLOGICAL TREATMENT AND MANAGEMENT OF HYPERHIDROSIS

INTRODUCTION

Idiopathichyperhidrosis is a dysfunctional disorder involving eccrine sweat glands and its impact on patients' daily quality of life is well-known. Unlike some years ago, when only poor effective and safe therapeutic alternatives were available, nowadays, several emerging pharmacological active substances have gained significant space as treatment options.

AREAS COVERED

The authors report on, in this narrative review, the emerging data from the literature focusing on the pharmacological treatments to draw up a drug treatments flow-chart for patients with idiopathic hyperhidrosis, taking into consideration specific differences among axillary, palmoplantar and craniofacial hyperhidrosis.

EXPERT OPINION

Idiopathic hyperhidrosis, regardless of the site of involvement, remains a functional disorder that places a significant burden on patients. After balancing efficacy against adverse events, systemic therapy, although off-label for all forms of hyperhidrosis can represent an additive therapeutic option for patients with insufficient response to topical treatment according to a step wise therapeutic approach. Until the pathophysiological mechanisms underlying hyperhidrosis are clear, and the etiological therapeutic approach become realistic, the greatest challenge in the therapeutic management of hyperhidrotic patients seems to be the search for the most convenient combination between different therapeutic modalities (topical and systemic agents, and botulinum toxins) to achieve long-term control of the disease symptoms.

Two-week prospective observational study of 5% sofpironium bromide gel in Japanese patients with primary axillary hyperhidrosis

In 2020, 5% sofpironium bromide (ECCLOCK^®) gel (hereinafter referred to as sofpironium) was approved in Japan for the topical treatment of primary axillary hyperhidrosis. A phase III study of sofpironium demonstrated the efficacy and safety of sofpironium; however, no study has assessed its early efficacy at <6 weeks after starting treatment. Therefore, to assess the earlier effectiveness of sofpironium, we conducted a 2‐week, single‐center, exploratory, prospective, observational study in Japanese patients with primary axillary hyperhidrosis. Patients aged ≥20 years and satisfying with a Hyperhidrosis Disease Severity Scale (HDSS) score of 3 or 4 at baseline were eligible for the study. The primary endpoint for the effectiveness was change in the proportion of patients with a HDSS score of 1, 2, 3, or 4 during the 2‐week study period. In 80 patients included in the full analysis set (FAS), there were more women than men (93.8% vs. 6.3%), and the mean age (±standard deviation [SD]) was 33.3 ± 9.4 years. In the FAS, the proportion of patients with a HDSS score of 1 or 2 was 55.0% on day 7, and statistically significant changes were observed after day 3 compared to baseline (p < 0.05). Mean HDSS scores (±SD) were significantly decreased from baseline value of 3.5 ± 0.5 to 2.4 ± 0.9 on day 7 (p < 0.001). The median period for sofpironium treatment to achieve a HDSS score of 1 or 2 for a continuous 2 days was 6 days (95% confidence interval, 4–8). Safety was evaluated in 92 patients in the safety analysis set, and no adverse events were reported during the study period of 2 weeks. These results suggest that after 1‐week treatment with sofpironium for patients with a HDSS score of 3 or 4, approximately 50% of the patients can achieve a HDSS score of 1 or 2, which is a clinically significant improvement for the patients.

A Practical Approach to the Diagnosis and Treatment of Palmar Hyperhidrosis

Palmar hyperhidrosis (PH), a condition characterized by excess sweating of the palms, is a common concern that presents to the plastic surgeon, which can have major impacts on patient confidence and quality of life. While several studies summarize treatment options for hyperhidrosis in general, few outline the therapeutic options available specifically for PH.

Measurement properties of patient-reported outcome measures (PROMs) in hyperhidrosis: a systematic review

PURPOSE

To critically appraise, compare and summarize the quality of all existing PROMs that have been validated in hyperhidrosis to at least some extend by applying the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Thereby, we aim to give a recommendation for the use of PROMs in future clinical trials in hyperhidrosis.

METHODS

We considered studies evaluating, describing or comparing measurement properties of PROMs as eligible. A systematic literature search in three big databases (MEDLINE, EMBASE and Web of Science) was performed. We assessed the methodological quality of each included study using the COSMIN Risk of Bias checklist. Furthermore, we applied predefined quality criteria for good measurement properties and finally, graded the quality of the evidence.

RESULTS

Twenty-four articles reporting on 13 patient-reported outcome measures were included. Three instruments can be further recommended for use. They showed evidence for sufficient content validity and moderate- to high-quality evidence for sufficient internal consistency. The methodological assessment showed existing evidence gaps for eight other PROMs, which therefore require further validation studies to make an adequate decision on their recommendation. The Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax) and the short-form health survey with 36 items (SF-36) were the only questionnaires not recommended for use in patients with hyperhidrosis due to moderate- to high-quality evidence for insufficient measurement properties.

CONCLUSION

Three PROMs, the Hyperhidrosis Quality of Life Index (HidroQoL), the Hyperhidrosis Questionnaire (HQ) and the Sweating Cognitions Inventory (SCI), can be recommended for use in future clinical trials in hyperhidrosis. Results obtained with these three instruments can be seen as trustworthy. Nevertheless, further validation of all three PROMs is desirable.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020170247.

Hyperhidrosis Comorbidities and Treatments: A Register-based Study among 511 Subjects

Hyperhidrosis is a dermatological condition that causes psychosocial impairment and has a negative impact on patients’ quality of life. The epidemiology of hyperhidrosis is currently poorly understood. The aim of this study was to analyse comorbidities and treatments in 511 subjects with hyperhidrosis selected from the patient records of Oulu University Hospital. The mean age of patients with local hyperhidrosis was 27.9 years and the majority were female (62.7%). The most common anatomical site of symptoms in the youngest age group was the palms, whereas the axillae were a more common site in advanced age. Depression was a common comorbidity in both local (11.6%) and generalized hyperhidrosis (28.6%). Anxiety affected 12.7% of patients with generalized hyperhidrosis. In 36.8% of the patients with local hyperhidrosis there was a delay in diagnosis of more than 10 years. The most commonly used treatments included topical antiperspirants, iontophoresis and botulin toxin injections.

Thoracoscopic resympathectomy for persistent or recurrent palmar hyperhidrosis: single-center experience

BACKGROUND

In case of recurrence or persistent palmar hyperhidrosis, a sympathetic chain resection is suggested, however, many surgeons are still reluctant to offer further intervention because of the inability to predict the efficacy of such a procedure. We analyzed our large series of resympathectomy.

METHODS

Substantive retrospective analysis of 39 patients underwent a resympathectomy (minimally invasive bilaterally sympathetic chain Th2-3 resection). Patients referred from other hospitals or primarily operated at our institution for recurrence or persistence palmar hyperhidrosis were included in the study group.

RESULTS

No intraoperative complications were detected. Reoperation or chest tube positioning was necessary in 2 patients. Twenty-eight patients had a positive response (excellent or good results). Seven patients described a substantial, but not sufficient, reduction of the symptomatology. Four patients were very unsatisfied and regretted the operation.

CONCLUSIONS

Resympathectomy is highly effective procedure for patients who have persistent or recurrent symptoms. However, the indication of the operations should be more dissuasive as possible to avoid the risk of any undesirable psychologically side effects.