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Rzany B, Bechara FG, Feise K, Heckmann M, Rapprich S, Wörle B. Update of the S1 guidelines on the definition and treatment of primary hyperhidrosis. J Dtsch Dermatol Ges 2019; 16:945-952. [PMID: 29989362 DOI: 10.1111/ddg.13579] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Focal hyperhidrosis can have a considerable impact on social and occupational activities and be associated with significant impairment in quality of life. Primary (idiopathic) hyperhidrosis is neither caused by systemic disorders nor by external factors. It usually occurs in areas characterized by a high density of sweat glands such as the axillae and hands. The diagnosis of focal hyperhidrosis is based on history and clinical findings. Supplementary diagnostic tests include gravimetry (measurement of the amount of sweat) and the iodine starch test (which shows the area of sweating). Treatment options consist of topical agents, botulinum toxin A injections, iontophoresis, treatment with radiofrequency, microwaves, or ultrasound as well as surgical procedures (axillary suction curettage, sympathectomy). Systemic agents such as anticholinergics may also be used. Selection of the most appropriate therapeutic approach depends on the site affected, prior treatment as well as the patient's requests.
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Affiliation(s)
- Berthold Rzany
- RZANY & HUND, Kurfürstendamm 183, 10707 Berlin, Deutschland
| | - Falk G Bechara
- Abteilung für Dermatochirurgie, Klinik für Dermatologie, Venerologie und Allergologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - Konstantin Feise
- Praxis Dr. Feise, Belegarzt Sophienklinik, Sophienstraße 41, 70178 Stuttgart, Deutschland
| | - Marc Heckmann
- Praxisklinik für Dermatologie, Kreuzstraße 26, 82319 Starnberg, Deutschland
| | - Stefan Rapprich
- Hautmedizin Bad Soden, Kronberger Straße 2, 65812 Bad Soden, Deutschland
| | - Birgit Wörle
- Dermatologie und Laserzentrum, Hirslanden Klinik Meggen, Klinik St. Anna AG, Meggen, Schweiz
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Wade R, Rice S, Llewellyn A, Moloney E, Jones-Diette J, Stoniute J, Wright K, Layton AM, Levell NJ, Stansby G, Craig D, Woolacott N. Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis. Health Technol Assess 2019; 21:1-280. [PMID: 29271741 DOI: 10.3310/hta21800] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Ros Wade
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Rice
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Eoin Moloney
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Julija Stoniute
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Nick J Levell
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Gerard Stansby
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, UK
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Leta V, van Wamelen D, Rukavina K, Jaakkola E, Sportelli C, Wan YM, Podlewska A, Parry M, Metta V, Chaudhuri K. Sweating and other thermoregulatory abnormalities in Parkinson’s disease: A review. ANNALS OF MOVEMENT DISORDERS 2019. [DOI: 10.4103/aomd.aomd_2_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rzany B, Bechara FG, Feise K, Heckmann M, Rapprich S, Wörle B. Aktualisierung der S1-Leitlinie zur Definition und Therapie der primären Hyperhidrose. J Dtsch Dermatol Ges 2018; 16:945-953. [DOI: 10.1111/ddg.13579_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Berthold Rzany
- RZANY & HUND; Kurfürstendamm 183; 10707 Berlin; Deutschland
| | - Falk G. Bechara
- Abteilung für Dermatochirurgie; Klinik für Dermatologie; Venerologie und Allergologie; Ruhr-Universität Bochum; Bochum Deutschland
| | - Konstantin Feise
- Praxis Dr. Feise; Belegarzt Sophienklinik; Sophienstraße 41; 70178 Stuttgart; Deutschland
| | - Marc Heckmann
- Praxisklinik für Dermatologie; Kreuzstraße 26; 82319 Starnberg; Deutschland
| | - Stefan Rapprich
- Hautmedizin Bad Soden; Kronberger Straße 2; 65812 Bad Soden; Deutschland
| | - Birgit Wörle
- Dermatologie und Laserzentrum; Hirslanden Klinik Meggen; Klinik St. Anna AG; Meggen Schweiz
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Wade R, Llewellyn A, Jones-Diette J, Wright K, Rice S, Layton AM, Levell NJ, Craig D, Woolacott N. Interventional management of hyperhidrosis in secondary care: a systematic review. Br J Dermatol 2018; 179:599-608. [PMID: 29573391 DOI: 10.1111/bjd.16558] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hyperhidrosis is uncontrollable excessive sweating, which occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life. OBJECTIVES To undertake a systematic review of the clinical effectiveness and safety of treatments available in secondary care for the management of primary hyperhidrosis. METHODS Fifteen databases (including trial registers) were searched to July 2016 to identify studies of secondary-care treatments for primary hyperhidrosis. For each intervention randomized controlled trials (RCTs) were included where available; where RCT evidence was lacking, nonrandomized trials or large prospective case series were included. Outcomes of interest included disease severity, sweat rate, quality of life, patient satisfaction and adverse events. Trial quality was assessed using a modified version of the Cochrane Risk of Bias tool. Results were pooled in pairwise meta-analyses where appropriate, otherwise a narrative synthesis was presented. RESULTS Fifty studies were included in the review: 32 RCTs, 17 nonrandomized trials and one case series. The studies varied in terms of population, intervention and methods of outcome assessment. Most studies were small, at high risk of bias and poorly reported. The interventions assessed were iontophoresis, botulinum toxin (BTX) injections, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland. CONCLUSIONS The evidence for the effectiveness and safety of treatments for primary hyperhidrosis is limited overall, and few firm conclusions can be drawn. However, there is moderate-quality evidence to support the use of BTX for axillary hyperhidrosis. A trial comparing BTX with iontophoresis for palmar hyperhidrosis is warranted.
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Affiliation(s)
- R Wade
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, U.K
| | - A Llewellyn
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, U.K
| | - J Jones-Diette
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, U.K
| | - K Wright
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, U.K
| | - S Rice
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, U.K
| | - A M Layton
- Harrogate and District NHS Foundation Trust, Harrogate, U.K
| | - N J Levell
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, U.K
| | - D Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, U.K
| | - N Woolacott
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, U.K
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Irmen M, Holze J, Bödefeld T, Tränkle C. Characterization of methanthelinium binding and function at human M 1-M 5 muscarinic acetylcholine receptors. Naunyn Schmiedebergs Arch Pharmacol 2018; 391:1037-1052. [PMID: 29938305 DOI: 10.1007/s00210-018-1525-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 06/07/2018] [Indexed: 11/24/2022]
Abstract
Firstly, it was determined whether methanthelinium bromide (MB) binds to human M1-M5 (hM1-hM5) muscarinic acetylcholine receptors in comparison to the classical muscarinic antagonist N-methylscopolamine (NMS). [3H]NMS dissociation binding experiments revealed an allosteric retardation of dissociation at 100 μM of MB ranging from none in hM3 to 4.6-fold in hM2 receptors. Accordingly, global non-linear regression analysis of equilibrium inhibition binding curves between [3H]NMS (0.2 and 2.0 nM) and MB was applied and compared using either an allosteric or a competitive model. The allosteric cooperativity of MB binding within MB/NMS/hM receptor complexes was strongly negative and undistinguishable from a competitive interaction throughout all subtypes. Applying the competitive model to the equilibrium binding data of MB and NMS, suggested competition at all hM subtypes: logKI (± S.E.) hM3 = 8.71 ± 0.15, hM1 = 8.68 ± 0.14, hM5 = 8.58 ± 0.07, hM2 = 8.27 ± 0.07 to hM4 = 8.25 ± 0.11. Secondly, the effects of MB on acetylcholine (ACh) induced hM receptor function showed very strong negative allosteric cooperativity at all subtypes pointing against an allosteric antagonism of MB with ACh. Competition with ACh was characterized by logKB: hM1 = 9.53 ± 0.05, hM4 = 9.33 ± 0.05, hM5 = 8.80 ± 0.05, hM2 = 8,79 ± 0.06, to hM3 = 8.43 ± 0.04. In conclusion, MB, below 1 μM, binds competitively and non-selectively (except for the difference between hM3 vs. hM4) to all five hM receptor subtypes with nanomolar affinity and is able to functionally inhibit ACh responses in a competitive fashion, with a slight subtype preference for hM1 and hM4.
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Affiliation(s)
- Matthias Irmen
- Pharmacology and Toxicology, Institute of Pharmacy, University of Bonn, Gerhard-Domagk-Straße 3, 53121, Bonn, Germany
| | - Janine Holze
- Pharmacology and Toxicology, Institute of Pharmacy, University of Bonn, Gerhard-Domagk-Straße 3, 53121, Bonn, Germany
| | - Theresa Bödefeld
- Pharmacology and Toxicology, Institute of Pharmacy, University of Bonn, Gerhard-Domagk-Straße 3, 53121, Bonn, Germany
| | - Christian Tränkle
- Pharmacology and Toxicology, Institute of Pharmacy, University of Bonn, Gerhard-Domagk-Straße 3, 53121, Bonn, Germany.
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Abstract
INTRODUCTION Hyperhidrosis affects 4.8% of the U.S. population and has been underestimated by physicians for long time despite considerable interference with quality of life. Many patients suffer from primary (idiopathic) hyperhidrosis which results from over-activity of sympathetic nerves and is restricted to specific body areas, mostly the axillae, palms, soles, or head. Secondary hyperhidrosis is caused by an underlying disease or the intake of medications and often involves large parts of the body. Numerous effective therapies with topical or systemic drugs and surgical options are available. Areas covered: Efficacy and safety data on aluminum salts, anticholinergic drugs for topical or systemic application, and on intradermal botulinum toxin injections used to treat hyperhidrosis are critically evaluated, including data from clinical trials with focus on possible side effects and long-term complications in dispute. Expert opinion: Hyperhidrosis often responds well to available therapies. Depending on the type of hyperhidrosis treatment should be topical/local or systemic. Most of the side effects are mild, transient and easily manageable. In case of systemic treatment with anticholinergics low dosing and up-titration of medication is necessary to avoid severe adverse effects. Concerns about the promotion of breast cancer and Alzheimer disease by topical aluminum salts are unsolved.
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Affiliation(s)
- Christine Hosp
- a Department of Dermatology, Venereology and Allergology , University Hospital Würzburg , Würzburg , Germany
| | - Henning Hamm
- a Department of Dermatology, Venereology and Allergology , University Hospital Würzburg , Würzburg , Germany
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Heinig B, Koch A, Wollina U. Palmar hyperhidrosis treated by noninvasive ultrasound stellate ganglion block. Wien Med Wochenschr 2016; 168:250-253. [PMID: 27379849 DOI: 10.1007/s10354-016-0468-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/19/2016] [Indexed: 11/29/2022]
Abstract
Focal palmar hyperhidrosis is a common and often debilitating eccrine sweat gland disorder with negative impact on quality of life and self-esteem. For treatment of recalcitrant cases, a stellate ganglion block is a nonsurgical alternative. Although this method has only a temporary effect, surgical risks can be avoided. The usual way to perform the block is by ultrasound-guided injection of local anesthetics. Here we describe the use of therapeutic ultrasound at 0.8 MHz for stellate ganglion block. Ultrasound was applied for 1 min unilaterally every other day for 6 days. The efficacy was monitored by video capillaroscopy and Minor's iodine starch test. Treatment was well tolerated and no adverse effects were noted. Sweating was stopped and capillary blood flow increased. The effect lasted for several weeks.
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Affiliation(s)
- Birgit Heinig
- Center of Physical and Rehabilitative Medicine, Academic Teaching Hospital Dresden-Friedrichstadt, Friedrichstrasse 41, 01067, Dresden, Germany
| | - Andrè Koch
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Friedrichstrasse 41, 01067, Dresden, Germany
| | - Uwe Wollina
- Department of Dermatology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Friedrichstrasse 41, 01067, Dresden, Germany.
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9
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Systemic Treatment of Hyperhidrosis. ACTAS DERMO-SIFILIOGRAFICAS 2015. [DOI: 10.1016/j.adengl.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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10
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Tratamiento sistémico de la hiperhidrosis. ACTAS DERMO-SIFILIOGRAFICAS 2015; 106:271-7. [DOI: 10.1016/j.ad.2014.11.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 11/05/2014] [Accepted: 11/19/2014] [Indexed: 11/21/2022] Open
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Costa ADS, Leão LEV, Succi JE, Perfeito JAJ, Filho Castelo A, Rymkiewicz E, Filho Aurelio Marchetti M. Randomized trial - oxybutynin for treatment of persistent plantar hyperhidrosis in women after sympathectomy. Clinics (Sao Paulo) 2014; 69:101-5. [PMID: 24519200 PMCID: PMC3912338 DOI: 10.6061/clinics/2014(02)05] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 07/27/2013] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Hyperhidrosis is a common disease, and thoracoscopic sympathectomy improves its symptoms in up to 95% of cases. Unfortunately, after surgery, plantar hyperhidrosis may remain in 50% of patients, and compensatory sweating may be observed in 70%. This clinical scenario remains a challenge. Our objective was to evaluate the effectiveness of oxybutynin in the treatment of persistent plantar hyperhidrosis and compensatory sweating and its effects on quality of life in women after thoracoscopic sympathectomy. METHOD We conducted a prospective, randomized study to compare the effects of oxybutynin at 10 mg daily and placebo in women with persistent plantar hyperhidrosis. The assessment was performed using a quality-of-life questionnaire for hyperhidrosis and sweating measurement with a device for quantifying transepidermal water loss. Clinicaltrials.gov: NCT01328015. RESULTS Sixteen patients were included in each group (placebo and oxybutynin). There were no significant differences between the groups prior to treatment. After oxybutynin treatment, there was a decrease in symptoms and clinical improvement based on the quality-of-life questionnaire (before treatment, 40.4 vs. after treatment, 17.5; p=0.001). The placebo group showed modest improvement (p=0.09). The outcomes of the transepidermal water loss measurements in the placebo group showed no differences (p=0.95), whereas the oxybutynin group revealed a significant decrease (p=0.001). The most common side effect was dry mouth (100% in the oxybutynin group vs. 43.8% in the placebo group; p=0.001). CONCLUSION Oxybutynin was effective in the treatment of persistent plantar hyperhidrosis, resulting in a better quality of life in women who had undergone thoracoscopic sympathectomy.
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Affiliation(s)
- Altair da Silva Costa
- Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São Paulo/SP, Brazil
| | - Luiz Eduardo Villaça Leão
- Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São Paulo/SP, Brazil
| | - José Ernesto Succi
- Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São Paulo/SP, Brazil
| | - Joao Aléssio Juliano Perfeito
- Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São Paulo/SP, Brazil
| | - Adauto Filho Castelo
- Federal University of São Paulo, Paulista School of Medicine, Department of Infectious Diseases, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Infectious Diseases, São Paulo/SP, Brazil
| | - Erika Rymkiewicz
- Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São Paulo/SP, Brazil
| | - Marco Filho Aurelio Marchetti
- Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São PauloSP, Brazil, Federal University of São Paulo, Paulista School of Medicine, Department of Thoracic Surgery, São Paulo/SP, Brazil
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Scheer F, Wiggermann P, Kamusella P, Wissgott C, Andresen R. CT-Assisted Sympathicolysis as an Additional Minimally Invasive Therapeutic Option in Primary Focal Plantar Hyperhidrosis. Cardiovasc Intervent Radiol 2014; 37:1554-8. [DOI: 10.1007/s00270-013-0824-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 11/29/2013] [Indexed: 11/29/2022]
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Lakraj AAD, Moghimi N, Jabbari B. Hyperhidrosis: anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel) 2013; 5:821-40. [PMID: 23612753 PMCID: PMC3705293 DOI: 10.3390/toxins5040821] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 03/27/2013] [Accepted: 04/12/2013] [Indexed: 11/18/2022] Open
Abstract
Clinical features, anatomy and physiology of hyperhidrosis are presented with a review of the world literature on treatment. Level of drug efficacy is defined according to the guidelines of the American Academy of Neurology. Topical agents (glycopyrrolate and methylsulfate) are evidence level B (probably effective). Oral agents (oxybutynin and methantheline bromide) are also level B. In a total of 831 patients, 1 class I and 2 class II blinded studies showed level B efficacy of OnabotulinumtoxinA (A/Ona), while 1 class I and 1 class II study also demonstrated level B efficacy of AbobotulinumtoxinA (A/Abo) in axillary hyperhidrosis (AH), collectively depicting Level A evidence (established) for botulinumtoxinA (BoNT-A). In a comparator study, A/Ona and A/Inco toxins demonstrated comparable efficacy in AH. For IncobotulinumtoxinA (A/Inco) no placebo controlled studies exist; thus, efficacy is Level C (possibly effective) based solely on the aforementioned class II comparator study. For RimabotulinumtoxinB (B/Rima), one class III study has suggested Level U efficacy (insufficient data). In palmar hyperhidrosis (PH), there are 3 class II studies for A/Ona and 2 for A/Abo (individually and collectively level B for BoNT-A) and no blinded study for A/Inco (level U). For B/Rima the level of evidence is C (possibly effective) based on 1 class II study. Botulinum toxins (BoNT) provide a long lasting effect of 3–9 months after one injection session. Studies on BoNT-A iontophoresis are emerging (2 class II studies; level B); however, data on duration and frequency of application is inconsistent.
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Affiliation(s)
- Amanda-Amrita D. Lakraj
- Department of Neurology, Yale University School of Medicine; New Haven, CT 06520, USA; E-Mail:
| | - Narges Moghimi
- Department of Neurology, Case Western Reserve University; Cleveland, OH 44106, USA; E-Mail:
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine; New Haven, CT 06520, USA; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +1-203-737-2464; Fax: +1-203-737-1122
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Müller C, Berensmeier A, Hamm H, Dirschka T, Reich K, Fischer T, Rzany B. Efficacy and safety of methantheline bromide (Vagantin(®) ) in axillary and palmar hyperhidrosis: results from a multicenter, randomized, placebo-controlled trial. J Eur Acad Dermatol Venereol 2012; 27:1278-84. [PMID: 23004926 DOI: 10.1111/j.1468-3083.2012.04708.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Focal hyperhidrosis can severely affect quality of life. So far, knowledge on the effect of systemic therapy of focal hyperhidrosis is limited. OBJECTIVE To assess the efficacy and safety of methantheline bromide (MB) in the treatment of axillary and palmar-axillary hyperhidrosis. METHODS A multicenter controlled randomized double-blind clinical trial was conducted in patients with axillary or palmar-axillary hyperhidrosis defined by a sweat production >50 mg/5 min. Patients received 3 × 50 mg MB daily or placebo over a period of 28 ± 1 days. Main outcome criterion was the reduction of sweat as measured by gravimetry on day 28 ± 1. Quality of life was assessed by Dermatology Life Quality Index (DLQI) and Hyperhidrosis Disease Severity Score (HDSS). RESULTS A total of 339 patients were randomly assigned to receive MB or placebo. On day 28 ± 1, the mean axillary sweat production was 99 mg for MB and 130 mg for placebo compared with 168 mg and 161 mg respectively at baseline (P = 0.004). Patient's HDSS score decreased in the MB group from 3.2 to 2.4 compared with 3.2 to 2.7 for placebo (P = 0.002). Similar results could be obtained for the DLQI with 9.7 for MB and 12.2 for placebo, which decreased from 16.4 or 17 respectively (P = 0.003). Tolerability was good for both groups. The most frequent adverse event was dry mouth. CONCLUSION Fifty milligrams methantheline bromide three times a day is an effective and safe treatment of axillary hyperhidrosis.
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Affiliation(s)
- C Müller
- Department of Medical Science and Operations, RIEMSER Arzneimittel AG, Greifswald, Germany Department of Dermatology, Venereology, and Allergology, University Hospital Würzburg, Würzburg, Germany Private Dermatological Practice Centre, Wuppertal, Germany SCIderm Research Institute and Dermatologikum Hamburg, Hamburg, Germany Skin and Laser Center Potsdam, Potsdam, Germany Division of Evidence-Based Medicine, Klinik für Dermatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Relative bioavailability and pharmacodynamic effects of methantheline compared with atropine in healthy subjects. Eur J Clin Pharmacol 2012; 68:1473-81. [PMID: 22527350 DOI: 10.1007/s00228-012-1286-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Methantheline is a strong muscarinic receptor blocking drug used in the treatment of overactive bladder syndrome, hypersalivation and hyperhidrosis. To provide basic information on the pharmacokinetics, magnitude of pharmacodynamic (PD) effects and their correlations with plasma concentrations, we performed a clinical study in 12 healthy subjects receiving methantheline as immediate-release coated tablets (IR) or in watery solution (SOL) in comparison with atropine and placebo tablets. METHODS The pharmacokinetics and influence of methantheline, atropine and placebo on salivation and accommodation and pupil function (pupillometry: diameter, response to light flash) were studied in a randomized, controlled study after the administration of 100 mg methantheline bromide as IR and in SOL (phase 1) and 1.0 mg atropine sulphate and placebo (phase 2). RESULTS Methantheline reached maximum plasma concentrations of approximately 25 ng/ml after 2.5-3 h and was eliminated at an apparent half-life of approximately 2 h. There was no pharmacokinetic (PK) bioequivalence of methantheline IR and SOL. The ratio IR/SOL (90 % confidence interval) were 0.892 (0.532-1.493) for AUC(0-∞) and 0.905 (0.516-1.584) for maximum plasma concentration. The PD effects of both forms were nearly equivalent with a IR/SOL ratio of 1.015 (0.815-1.262) for salivation, which is the most susceptible characteristic. Methantheline reduced salivation at a potency (methantheline concentration at half maximum effects, EC₅₀) of 5.5 ng/ml in accordance with it plasma concentration. The antimuscarinic effects observed after methantheline administration were stronger and persisted longer than those following the administration of atropine. CONCLUSIONS Methantheline is slowly absorbed but rapidly eliminated in humans, and it exerts a strong effect on salivation which is closely associated with its plasma concentrations following a standard sigmoid PD model. Immediate-release tablets and a watery solution of methantheline are equivalent in terms of major PD effects (salivation, pupil function, heart rate) despite its high PK variability.
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Abstract
Hyperhidrosis is characterized by localized or general excessive sweating which is severe enough to be perceived as pathological. Since excessive sweating often starts in childhood and adolescence, usually in children between 6 and 16 years of age, hyperhidrosis is an important disorder for children and juveniles. This condition causes considerable disruption of both social life and educational career, leading to severe deterioration in the patient's quality of life. In addition, therapy is often challenging since many treatment modalities are not approved for children. Nonetheless, there are still effective therapeutic options for children with hyperhidrosis.
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Hoorens I, Ongenae K. Primary focal hyperhidrosis: current treatment options and a step-by-step approach. J Eur Acad Dermatol Venereol 2011; 26:1-8. [PMID: 21749468 DOI: 10.1111/j.1468-3083.2011.04173.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Primary focal hyperhidrosis is a common disorder for which treatment is often a therapeutic challenge. A systematic review of current literature on the various treatment modalities for primary focal hyperhidrosis was performed and a step-by-step approach for the different types of primary focal hyperhidrosis (axillary, palmar, plantar and craniofacial) was established. Non-surgical treatments (aluminium salts, local and systemic anticholinergics, botulinum toxin A (BTX-A) injections and iontophoresis) are adequately supported by the current literature. More invasive surgical procedures (suction curettage and sympathetic denervation) have also been extensively investigated, and can offer a more definitive solution for cases of hyperhidrosis that are unresponsive to non-surgical treatments. There is no consensus on specific techniques for sympathetic denervation, and this issue should be further examined by meta-analysis. There are numerous treatment options available to improve the quality of life (QOL) of the hyperhidrosis patient. In practice, however, the challenge for the dermatologist remains to evaluate the severity of hyperhidrosis to achieve the best therapeutic outcome, this can be done most effectively using the Hyperhidrosis Disease Severity Scale (HDSS).
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Affiliation(s)
- I Hoorens
- Department of Dermatology, University Hospital, Ghent, Belgium.
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Wozniacki L, Zubilewicz T. Primary hyperhidrosis controlled with oxybutynin after unsuccessful surgical treatment. Clin Exp Dermatol 2010; 34:e990-1. [PMID: 20055880 DOI: 10.1111/j.1365-2230.2009.03645.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schlereth T, Dieterich M, Birklein F. Hyperhidrosis--causes and treatment of enhanced sweating. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:32-7. [PMID: 19564960 DOI: 10.3238/arztebl.2009.0032] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 11/03/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND Basically two types of sweating exist: thermoregulatory and emotional sweating. They are controlled by different centers: thermo regulatory sweating is regulated predominantly by the hypothalamus, emotional sweating predominantly by the limbic system. Enhanced sweating, called hyperhidrosis, can be generalized or focal. Primary focal hyperhidrosis is the most common type and affects the axillae, hands, feet, and face--areas principally involved in emotional sweating. Secondary hyperhidrosis develops due to dysfunction of the central or peripheral nervous system. METHODS Review based on a selective search of the literature via Medline and on the guidelines of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften [AWMF]). RESULTS Various conservative and surgical treatments exist for hyperhidrosis. Conservative treatment options are the local application of aluminum chloride, tap water iontophoresis, and the intracutaneous injection of botulinum toxin. Surgical approaches include endoscopic sympathectomy and axillary tumescent curettage and liposuction, removing the sweat glands. Systemic drugs (e.g. anticholinergic substances) can be used in the treatment of generalized hyperhidrosis. CONCLUSION A step-by-step approach is recommended for the treatment of hyperhidrosis. Local treatment options with few and minor side effects should be tried first.
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Affiliation(s)
- Tanja Schlereth
- Klinik für Neurologie, Johannes Gutenberg-Universität Mainz, Germany.
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Reisfeld R, Berliner KI. Evidence-Based Review of the Nonsurgical Management of Hyperhidrosis. Thorac Surg Clin 2008; 18:157-66. [DOI: 10.1016/j.thorsurg.2008.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lifestyle-Medikamente in der Medizin. Wien Med Wochenschr 2008; 158:110-5. [DOI: 10.1007/s10354-007-0473-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Accepted: 07/10/2007] [Indexed: 10/22/2022]
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Affiliation(s)
- Birgit Wörle
- Rosenpark Clinic Ltd. Clinic for Aesthetic-Surgical Drematology and Plastic Surgery, Darmstadt, Germany.
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