Treatment of axillary hyperhidrosis with botulinum-A toxin

Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis

BACKGROUND

Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. The management of hyperhidrosis is uncertain and variable.

OBJECTIVE

To establish the expected value of undertaking additional research to determine the most effective interventions for the management of refractory primary hyperhidrosis in secondary care.

METHODS

A systematic review and economic model, including a value-of-information (VOI) analysis. Treatments to be prescribed by dermatologists and minor surgical treatments for hyperhidrosis of the hands, feet and axillae were reviewed; as endoscopic thoracic sympathectomy (ETS) is incontestably an end-of-line treatment, it was not reviewed further. Fifteen databases (e.g. CENTRAL, PubMed and PsycINFO), conference proceedings and trial registers were searched from inception to July 2016. Systematic review methods were followed. Pairwise meta-analyses were conducted for comparisons between botulinum toxin (BTX) injections and placebo for axillary hyperhidrosis, but otherwise, owing to evidence limitations, data were synthesised narratively. A decision-analytic model assessed the cost-effectiveness and VOI of five treatments (iontophoresis, medication, BTX, curettage, ETS) in 64 different sequences for axillary hyperhidrosis only.

RESULTS AND CONCLUSIONS

Fifty studies were included in the effectiveness review: 32 randomised controlled trials (RCTs), 17 non-RCTs and one large prospective case series. Most studies were small, rated as having a high risk of bias and poorly reported. The interventions assessed in the review were iontophoresis, BTX, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland (e.g. laser, microwave). There is moderate-quality evidence of a large statistically significant effect of BTX on axillary hyperhidrosis symptoms, compared with placebo. There was weak but consistent evidence for iontophoresis for palmar hyperhidrosis. Evidence for other interventions was of low or very low quality. For axillary hyperhidrosis cost-effectiveness results indicated that iontophoresis, BTX, medication, curettage and ETS was the most cost-effective sequence (probability 0.8), with an incremental cost-effectiveness ratio of £9304 per quality-adjusted life-year. Uncertainty associated with study bias was not reflected in the economic results. Patients and clinicians attending an end-of-project workshop were satisfied with the sequence of treatments for axillary hyperhidrosis identified as being cost-effective. All patient advisors considered that the Hyperhidrosis Quality of Life Index was superior to other tools commonly used in hyperhidrosis research for assessing quality of life.

LIMITATIONS

The evidence for the clinical effectiveness and safety of second-line treatments for primary hyperhidrosis is limited. This meant that there was insufficient evidence to draw conclusions for most interventions assessed and the cost-effectiveness analysis was restricted to hyperhidrosis of the axilla.

FUTURE WORK

Based on anecdotal evidence and inference from evidence for the axillae, participants agreed that a trial of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis would be most useful. The VOI analysis indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear that such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015027803.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Comparative Study of Efficacy and Safety of Botulinum Toxin a Injections and Subcutaneous Curettage in the Treatment of Axillary Hyperhidrosis

BACKGROUND

Primary focal axillary hyperhidrosis is a chronic distressing disorder affecting both the sexes. When the condition is refractory to conservative management, we should go for more promising therapies like intradermal botulinum toxin A (BtxA) injections in the axilla, and surgical therapies like subcutaneous curettage of sweat glands.

AIMS AND OBJECTIVES

The aim of this study is to compare the efficacy, safety and duration of action of intradermal BtxA injections in one axilla and subcutaneous curettage of sweat glands in the other axilla of the same patient with axillary hyperhidrosis.

MATERIALS AND METHODS

Twenty patients (40 axillae) received intradermal BtxA injections on the right side (20 axillae) and underwent tumescent subcutaneous curettage of sweat glands on the left side (20 axillae). Sweat production rate was measured using gravimetry analyses at baseline and at 3 months after the procedure. Subjective analyses were done using hyperhidrosis disease severity scale (HDSS) score at baseline, at 3^rd and 6^th month after the procedure.

RESULTS

At 3 months post-treatment, the resting sweat rate in the toxin group improved by 80.32% versus 79.79% in the subcutaneous curettage method (P = 0.21). Exercise-induced sweat rate in the toxin group improved by 88.76% versus 88.8% in the subcutaneous curettage group (P = 0.9). There was a significant difference in the HDSS score after treatment with both the modalities. There were no adverse events with BtxA treatment compared to very minor adverse events with the surgical method.

CONCLUSION

Both intradermal BtxA injections and tumescent subcutaneous curettage of sweat glands had a significant decrease in the sweat rates with no significant difference between the two modalities. Hence, in resource poor settings where affordability of BtxA injection is a constraint, subcutaneous curettage of sweat glands can be preferred which has been found equally effective with no or minimal adverse events.

A preliminary study of painless and effective transdermal botulinum toxin A delivery by jet nebulization for treatment of primary hyperhidrosis

Background

Hyperhidrosis is a chronic disease characterized by increased sweat production. Local injections of botulinum toxin A (BTX-A) have been extensively used for treatment of primary hyperhidrosis (idiopathic). The current treatment for this condition involves several intradermal injections, resulting in poor patient compliance due to injection-related pain. Therefore, new protocols, including an improved anesthetic regimen, are required.

Aim

We designed the present study to determine whether JetPeel™-3, a medical device used for transdermal delivery of drugs by jet nebulization, could be used to deliver lidocaine prior to the standard multiple BTX-A injections or deliver lidocaine together with BTX-A in order to determine the protocol giving better results in terms of procedure-related pain, sweating, and patient satisfaction in subjects affected by primary axillary, palmar or plantar hyperhidrosis.

Materials and methods

Twenty patients with a visual analog scale (VAS) sweating score ≥ 8 cm were randomized to receive lidocaine 2% (5 mL) delivered by JetPeel™-3 followed by multiple injections of BTX-A (100 units) or lidocaine 2% (5 mL) and BTX-A (50 units) delivered together by JetPeel™-3. Effect of treatment on sweating was measured by VAS (0= minimum sweating; 10= maximum sweating) at 3-month follow-up. Pain induced by the procedure was assessed by VAS (0= minimum pain; 10= maximum pain) immediately after the procedure. Patient satisfaction was assessed at 3-month follow-up using a 5-point scale (1= not at all satisfied; 2= not satisfied; 3= partially satisfied; 4= satisfied; 5= highly satisfied).

Results

Both treatment modalities reduced sweating at 3-month follow-up, if compared with baseline (all P<0.001). Delivery of lidocaine and BTX-A by JetPeel™-3 resulted in lower procedure-related pain and reduced sweating, if compared with lidocaine delivered by JetPeel™-3 followed by multiple BTX-A injections (all P<0.001). Patient satisfaction with the procedure was higher in the group receiving lidocaine and BTX-A treatment by JetPeel™-3, if compared with lidocaine delivered by JetPeel™-3 followed by multiple BTX-A injections (P<0.001). No side effects were observed in both groups.

Conclusion

Lidocaine and BTX-A can be safely delivered together by JetPeel™-3 to treat primary palmar, plantar and axillary hyperhidrosis, resulting in lower procedure-related pain, improved sweating and higher patient satisfaction, if compared with lidocaine delivered by JetPeel™-3 followed by standard BTX-A injection therapy. Our protocol delivering lidocaine and BTX-A together by JetPeel™-3 requires a reduced quantity of BTX-A, further supporting the use of the transdermal drug delivery by jet nebulization over standard injection therapy for treatment of primary hyperhidrosis.

Comparison of intradermal injection with iontophoresis of abobotulinum toxin A for the treatment of primary axillary hyperhidrosis: a randomized, controlled trial

BACKGROUND

Botulinum neurotoxin type A (BTX-A) injection is the treatment of choice for idiopathic axillary hyperhidrosis (IAH) refractory to conventional treatments.

OBJECTIVE

This study compared the efficacy of BTX-A injection and iontophoresis for treatment of IAH in a randomized controlled trial.

METHODS

In eleven patients with the diagnosis of IAH, one axilla was randomly treated with injections of 1.5 mL (250 MU) of BTX-A, and the other side was treated with BTX-A administered by iontophoresis. The amount of sweating, skin hydration, transepidermal water loss, pain, and patient satisfaction on both axilla were compared with baseline levels, and also between both sides 1 week, 1 month, and 6 months after treatment.

RESULTS

The injection side had significantly less sweat production than the iontophoresis side 1 week, 1 month, and 6 months after treatment (84%, 76%, and 50% vs. 73%, 22%, and 32%, respectively). The response to iontophoresis was more stable than that to injection. Participants' pain perception during the procedure score was significantly less on the iontophoresis side compared with the injection side (15.0 vs. 20.0, p < 0.05).

CONCLUSION

This study has shown that injection is a more effective method for the administration of BTX-A, though iontophoresis can also be considered a non-invasive and painless method in some patients.

Treatment of primary axillary hyperhidrosis with botulinum toxin type a: our experience in 50 patients from 2007 to 2010

Background. Local injections of Botulinum toxin type A (BTX-A) are an effective and safe solution for primary bilateral axillary hyperhidrosis. Traditional treatments are often ineffective and difficult to tolerate. This study was performed to assess the efficacy and safety of Botulinum toxin type A in the treatment of these diseases and to evaluate the reliability of patient's subjective rating in the timing of repeat injections. Methods. From 2007 to 2008, we included in the study and treated a total of 50 patients, and we used the Minor's iodine test and the hyperhidrosis diseases severity scale as initial inclusion criteria and also for evaluating the followup, comparing to patient's subjective rating. We used also a specific questionnaire to evaluate the level of pain, the onset of the effect, any eventual adverse effect of the treatment, the onset of compensatory hyperhidrosis, and the global grade of satisfaction. The data were analyzed using standard statistical methods. Results. 88% of patients were totally satisfied and all patients repeated the treatment during all the study. The symptom-free interval was in median 6 months with an average improving of HDSS of 1.5 points. In 86%, there was a complete accordance between the subjective patient's demand of the repetition of the treatment and the positivity to Minor test and HDSS. No major side effects happened. Conclusion. Local injections of Botulinum toxin type A (BTX-A) result in an effective and safe solution for bilateral axillary primary hyperhidrosis for the absence of significant morbidity, side effects, and lack of efficacy or duration. The only defects are the need of repetition of the treatment and relative costs.

Botulinum toxin for hyperhidrosis: a review

Primary focal hyperhidrosis is a disorder of idiopathic excessive sweating that typically affects the axillae, palms, soles, and face. The disorder, which affects up to 2.8% of the US population, is associated with considerable physical, psychosocial, and occupational impairments. Current therapeutic strategies include topical aluminum salts, tap-water iontophoresis, oral anticholinergic agents, local surgical approaches, and sympathectomies. These treatments, however, have been limited by a relatively high incidence of adverse effects and complications. Non-surgical treatment complications are typically transient, whereas those of surgical therapies may be permanent and significant. Recently, considerable evidence suggests that botulinum toxin type A (BTX-A) injections into hyperhidrotic areas can considerably reduce focal sweating in multiple areas without major adverse effects. BTX-A has therefore shown promise as a potential replacement for more invasive treatments after topical aluminum salts have failed. This article reviews the epidemiology, diagnosis, and management of primary focal hyperhidrosis, with an emphasis on recent research evidence supporting the use of BTX-A injections for this indication.

Efficacy of botulinum toxin type A in the treatment of focal axillary hyperhidrosis

BACKGROUND

Local intradermal injection of botulinum toxin Type A has become a recognized treatment for axillary hyperhidrosis. This study has investigated the efficacy of this method of treatment in terms of symptom-free interval between treatments and patients' satisfaction. We also investigated the reliance on patients' subjective assessment of the recurrence of symptoms in determining the timing of repeat injections.

METHODS

All patients referred to our clinic between May 2001 and December 2005 with a diagnosis of focal primary axillary hyperhidrosis were included in this study. Data were collected prospectively in a standard proforma. Every patient received a questionnaire to complete over a 4-week period. The questionnaire included visual analogue scales for periprocedural pain, degree of dryness, satisfaction, regret, and complications. Final symptom-free interval was recorded when the patient requested a repeat injection. The data were recorded on a spreadsheet and analyzed using standard statistical methods.

RESULTS

A total of 52 consecutive patients and 238 axillary injections were analyzed. The symptom-free interval ranged from 3 to 14 months with a median of 5.97 months. There were no significant complications from this treatment modality. A total of 97% of the patients were highly satisfied with only 1 patient regretting the treatment.

CONCLUSION

Botulinum toxin Type A is an effective and well-tolerated treatment for axillary hyperhidrosis. Timing of repeat injections as determined subjectively by patients is comparable to studies using colorimetric and gravimetric techniques to quantify the severity of sweating prior to the administration of repeat injections. The authors have indicated no significant interest with commercial supporters.

A randomized pilot study comparing the action halos of two commercial preparations of botulinum toxin type A

BACKGROUND

The determination of the action halos of botulinum toxin type A aids in targeting specific muscles and/or sweat glands, thereby preventing the occurrence of side effects.

OBJECTIVES

The objective of this study was to compare the action halos of two commercial preparations of botulinum toxin type A, Dysport (Ipsen, Slough, UK) and BOTOX (Allergan, Irvine, CA).

MATERIAL AND METHODS

Eighteen volunteers received applications of both products into randomized sides of the frontalis muscle. Equivalent doses of 5 U of Dysport and 2 U of BOTOX were injected using the same technique, in the same volume (0.02 mL), and at a controlled depth. Twenty-eight days later, clinical and photographic assessments were performed.

RESULTS

All the areas around the injected points were regular, round, or slightly oval and showed similar effects in the muscles and sweat glands. No statistically significant differences were observed between the mean sizes of the diameters of the halos produced by the two products.

CONCLUSION

Injections of Dysport and BOTOX at an equivalence ratio of 2.5:1 U, respectively, applied at the same volume and depth, using the same technique resulted in similar action halos with regard to muscular and sweat gland activity. Both products seem to be safe and very predictable.

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.

Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety

BACKGROUND

The long-term effects of botulinum toxin type A (BoNTA) on the global impairment associated with severe primary axillary hyperhidrosis have not been comprehensively assessed relative to placebo.

OBJECTIVE

To assess the efficacy and safety of 2 dosages of BoNTA compared with placebo in subjects with primary axillary hyperhidrosis.

METHODS

Subjects (N = 322) were randomized to the use of BoNTA (75 U or 50 U/axilla) or placebo in this 52-week, multicenter, double-blind study.

RESULTS

BoNTA treatment significantly reduced daily activity limitations at 4 weeks after injection. A 2-point improvement on the 4-point Hyperhidrosis Disease Severity Scale (HDSS) was reported in 75% of subjects in the 75-U and 50-U BoNTA groups and in 25% of the placebo group (P < .001). Improvements in HDSS scores were corroborated by gravimetric results. The median duration of effect was 197 days, 205 days, and 96 days in the 75-U, 50-U, and placebo groups, respectively. BoNTA was well tolerated.

LIMITATIONS

The effect of total surface area involvement on treatment efficacy was not evaluated.

CONCLUSION

BoNTA treatment effectively reduces the symptoms of primary axillary hyperhidrosis and is well tolerated.

Primary Focal Hyperhidrosis: Disease Characteristics and Functional Impairment

BACKGROUND

There are few published data on the clinical characteristics of hyperhidrosis.

OBJECTIVE

To describe the functional impairment caused by primary focal hyperhidrosis.

METHODS

Patients with hyperhidrosis (n = 345) were enrolled at the Department of Dermatology, University of Würzburg. Controls (n = 154) were a convenience sample of subjects without hyperhidrosis. Hyperhidrosis characteristics, health-related quality of life and functional impairment were assessed.

RESULTS

Patients with axillary hyperhidrosis reported a later age at onset and a higher prevalence of a family history of hyperhidrosis than patients with palmar hyperhidrosis. Sixty-three percent of patients reported occupational impairment related to hyperhidrosis. Hyperhidrosis patients reported emotional and physical impairment, with a greater proportion of the axillary group reporting impairment. More than 50% of patients reported moderate to extreme impairment in personal relationships and in social situations.

CONCLUSION

Primary focal hyperhidrosis is a serious medical condition, affecting work productivity, daily activities, emotional well-being and personal relationships.

Treatment of hyperhidrosis with botulinum toxin

Focal idiopathic and episodic eccrine sweating of the axillae, palms, soles, and face troubles afflicted individuals with a social curse that can only be imagined by those whose hands or underarms dampen only occasionally. Although there is no accurate incidence in the epidemiology literature, it seems that about half of the patients who have presented to the author with this condition have at least one first-degree relative similarly affected. Social stigma, lack of understanding on the part of medical providers as to the cause and nature of the problem, and lack of effective therapy keeps most of these patients from seeking medical care. This article investigates the treatment of hyperhidrosis with botulinum toxin.

Sweating dysfunction in Parkinson's disease

We sought to determine the prevalence and nature of sweating disturbances in patients with Parkinson's disease (PD), and investigated their correlation with other clinical features and with Quality of Life (QoL) measures. A questionnaire on symptoms and consequences of sweating dysfunction was completed by 77 consecutive outpatients, from three movement disorder clinics, and 40 controls. QoL was assessed using the disease-specific Parkinson's Disease Questionnaire (PDQ)-39 and generic EuroQoL (EQ)-5D rating scales. Patients also underwent a clinical examination, including assessment with the Unified Parkinson's Disease Rating Scale and the Hoehn and Yahr staging system. Sweating disturbances, either hypohidrosis or in particular, hyperhidrosis, were reported by 64% of patients and by 12.5% of controls (P < 0.005) and were often localised or asymmetric. Complaints of sweating disturbances were not correlated with disease severity, but did correlate with other symptoms of autonomic dysfunction. Sweating problems occurred predominantly in off periods and in on periods with dyskinesias. Sweating disturbances were not correlated with overall QoL scores, but we did observe a significant correlation with the pain dimension of the PDQ-39 and the visual analogue scale of the EQ-5D. Furthermore, many patients reported physical, social, and emotional impairment due to sweating. Sweating disturbances are common and distressing symptoms of PD that are related mainly to autonomic dysfunction, off periods, and dyskinesias.

Botulinum toxin in the treatment of axillary hyperhidrosis

INTRODUCTION

Axillary hyperhidrosis can be a source of social isolation and embarrassment. The available treatments are either ineffective or have intolerable side effects. The search for a simple, long-lasting, and safe treatment has led to the use of botulinum-A toxin injections in those with excessive axillary hyperhidrosis.

MATERIALS AND METHODS

Fifteen patients participated in this study. All had a history of axillary hyperhidrosis of 1-6 years duration and were using different types of therapies without any benefit. Each patient was injected intradermally with 125 units of botulinum-A toxin (Dysport, Spenywood Pharmaceutical) in 5-6 points over an elliptical area on each side. Patient follow-up was performed using the iodine-starch test.

RESULTS

A total of 14 out of the 15 patients had complete anhidrosis 1 week after the injection. This result lasted for periods ranging from 1-6 months. No side effects were encountered.

CONCLUSION

Intradermal injection of botulinum-A toxin seems to be a safe, rapid, and effective method of treatment in axillary hyperhidrosis.

Evaluation of the impact of transthoracic endoscopic sympathectomy on patients with palmar hyperhydrosis

OBJECTIVES

We assessed the impact of transthoracic endoscopic sympathectomy (TES) on the quality of life of patients with palmar hyperhydrosis.

DESIGN

A retrospective questionnaire based study.

METHODS

Patients undergoing TES at our institution between 1997 and 2002 received a SF-36 quality of life postal questionnaire. The pre- and post-operative symptoms were assessed. Statistical analysis was by means of the Student's t test.

RESULTS

Ninety-four TES were carried out in 62 patients. Forty-one cases were female. The age range was 17-64 years. The mean follow-up period was 38.46 months. Mean hospital stay was 3 days. Compensatory hyperhydrosis was reported in 29 cases and only considered severe in four cases (9.7%). Forty-one patients replied to the questionnaire (66%). The overall quality of life (as assessed by the SF-36 form) was unanimously improved (p<0.0009) and demonstrated significant improvements in social functioning (p<0.0002), physical role limitations (p<0.0007), emotional well-being (p<0.0007) and overall energy levels (p<0.05).

CONCLUSION

TES resulted in significant improvements inpatient's overall quality of life, social and emotional functioning. The procedure is associated with minimal morbidity and only a short inpatient stay is required. Patients should be cautioned on the possibility of compensatory hyperhydrosis which may occur in a small number of cases.

Hyperhidrosis and botulinum toxin A: patient selection and techniques

Focal idiopathic excessive eccrine sweating presents most commonly as an affliction of three anatomically distinct area: the axillae, the palms and soles, and the upper face. The true incidence is not known, but about half of the patients referred to us with this condition have at least one first-degree relative similarly affected. Only a fraction of patients afflicted are thought to seek medical care because of the social stigma, lack of understanding on the part of medical providers as to the cause and nature of the problem, and, until now, lack of effective nonsurgical therapy. A large social sample is required to accurately measure both the incidence and the exact nature of the genetic influence.

Botulinum Toxin for the Treatment of Facial Flushing

BACKGROUND

Facial flushing is a common problem that is encountered by fair-skinned patients of Celtic and Northern European descent. Although usually transient in nature, some patients display a persistent reddened skin tone, with periods of increased erythema. Treatment of this condition is limited.

OBJECTIVE

To describe a novel method for the treatment of persistent facial flushing.

METHOD

We report a case of persistent facial flushing that was resistant to multiple pulsed dye laser treatments and was successfully treated with botulinum toxin A.

RESULTS

The posttreatment appearance was dramatic, and the patient was highly satisfied with the cosmetic outcome.

CONCLUSION

Botulinum toxin A can be used in small quantities to decrease persistent facial flushing temporarily.