Treatment of axillary hyperhidrosis: combination of the starch-iodine test with the tumescent liposuction technique

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.

Comparative Study of En Bloc Excision and Dermal Shaving in Treating Axillary Osmidrosis

BACKGROUND

Axillary osmidrosis is a distressing problem caused by hyperactivity of apocrine glands. There have been numerous studies on various surgical treatment methods. In this study, we evaluated the effectiveness of en bloc excision in comparison with dermal shaving.

METHODS

The electronic records of 146 patients (286 axillae) who underwent surgery at our center for axillary osmidrosis between January 2009 and December 2020 were reviewed. Twenty-five patients (49 axillae) underwent en bloc excision and 121 (237 axillae) underwent dermal shaving. Patients in the en bloc excision group underwent Minor test preoperatively to detect sweating areas. Severity of osmidrosis was graded using a 4-point scale (0-3). A satisfaction questionnaire was used to evaluate patient experiences in the 2 types.

RESULTS

Mean operation time was significantly shorter in the en bloc excision group than in dermal shaving group. Most en bloc excisions were performed on an outpatient basis under local anesthesia. Both groups showed an improvement in osmidrosis score at 6 months after surgery. A satisfaction questionnaire revealed better perioperative experiences in the en bloc excision group. Various surgical complications such as hematoma, wound dehiscence, and flap necrosis occurred in the dermal shaving group, and the en bloc excision group experienced significantly fewer complications that required intervention.

CONCLUSIONS

En bloc excision combined with Minor test effectively reduces malodor without causing severe complications. In addition, perioperative patient satisfaction was better in the en bloc excision group than in the dermal shaving group as en bloc excision provided more rapid returns to normality and simplified communications with patients.

Effectiveness and safety of the improved mini-incision surgery for osmidrosis treatment

BACKGROUND

As the mainstream treatment of axillary osmidrosis, surgical treatment is still limited by various complications, such as paresthesia, scars, local infection, hematoma, flap necrosis, and long recovery time. In this study, we tried to adopt the improved mini-incision surgery for osmidrosis treatment.

OBJECTIVES

The paper aims to evaluate the clinical effectiveness and safety of the improved mini-incision surgery for axillary osmidrosis treatment.

PATIENTS/METHODS

Clinical series of patients underwent improved mini-incision surgery were retrospectively reviewed. Dates of complications, including paresthesia, scars, infection, hematoma, skin necrosis, and recurrence were analyzed.

RESULTS

Among 61 cases, 58 cases had a preoperative osmidrosis score of 3 and 3 cases had a preoperative score of 2; while 13 cases had a postoperative osmidrosis score of 0, 43 cases had a postoperative score of 1 and 5 cases had a postoperative score of 2, significantly lower than that before (p < 0.001). A total of 12 axillae complications occurred, 2 axillae (1.6%) had paresthesia; 5 axillae (4.1%) had hematoma; 2 axillae (1.6%) had local flap necrosis due to hematoma; and 3 axillae (2.4%) had hypertrophic scars.

CONCLUSIONS

The results showed that the improved mini-incision surgery was safe and effective for osmidrosis treatment.

The color of skin: black diseases of the skin, nails, and mucosa

Gradations in skin color are a consequence of differing amounts of melanin and their varying distribution. Although many darkly pigmented skin lesions are melanocytic and can be attributed to melanin content, the color of a black lesion can also be due to blood, necrotic tissue, or exogenous pigment. The source, pattern, and distribution of the color in black lesions usually offer important insight into its etiology. This contribution reviews conditions that can take on a black color, discussing the cause of the hue and any additional impact sun exposure may have.

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.

Surgical treatment of axillary hyperhidrosis by suction-curettage of sweat glands

Suction curettage is a dermatologic surgery technique for the treatment of axillary hyperhidrosis, which is becoming more popular.

OBJECTIVE

The purpose of this study is to describe the current technique of removal of axillary sweat glands, and evaluate its efficacy and safety.

CONCLUSION

Suction-curettage of sweat glands is a minimally invasive surgical technique that is easy to perform, safe, has high rates of success and relatively few side-effects. It is generally well tolerated by patients and requires shorter time away from daily activities, when compared with other surgical modalities.

Modified tumescent superficial suction with curettage treatment for axillary bromidrosis: clinical experience of 280 cases

BACKGROUND

Axillary bromidrosis adversely affects patients' social and personal life with excessive malodor. Although surgical resection of the apocrine glands is one effective and irreversible method for treating axillary bromidrosis, the postoperation complications cannot be ignored. This study aimed to evaluate the long-term outcome of the authors' modified tumescent superficial suction with a curettage procedure for axillary bromidrosis treatment.

METHODS

From January 2010 to December 2012, 450 patients with axillary bromidrosis visited the authors' plastic surgery outpatient department and received the modified treated using tumescent superficial suction with a curettage procedure. A total of 170 patients were lost to follow-up evaluation and eliminated from this study.

RESULTS

The follow-up period ranged from 5 to 35 months (mean 15.5 months). Among 280 patients, 261 (93.2 %) showed excellent to good results. Reoperation with the same procedure was performed for 15 patients, and all had excellent results afterward. The most common postoperative complication was transient ecchymosis (23.6 %).

CONCLUSION

The modified suction and curettage procedure is an optimal therapeutic strategy for axillary bromidrosis treatment.

LEVEL OF EVIDENCE IV

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 .

Treatment of Axillary Osmidrosis Using a Subcutaneous Pulsed Nd-YAG Laser

Background

Axillary osmidrosis is characterized by an unpleasant odor, profuse sweating, and in some instances, staining of clothes that may socially and psychologically impair affected individuals. Various types of surgical procedures have been developed for the treatment of axillary osmidrosis. This study was undertaken to evaluate the effectiveness of subcutaneous pulsed neodymium: yttrium-aluminum-garnet (Nd-YAG) laser treatment for the treatment of axillary osmidrosis.

Methods

Twenty-nine patients with axillary osmidrosis were included in this study. Patients were categorized according to the results of an axillary malodor grading system, and a subcutaneous pulsed Nd-YAG laser was applied to all patients. The treatment area for the appropriate distribution of laser energy was determined using the iodine starch test (Minor's test) against a grid pattern composed of 2×2 cm squares. The endpoint of exposure was 300 to 500 J for each grid, depending on the preoperative evaluation results. The results were evaluated by measurement of axillary malodor both pre- and postoperatively using the grading system and iodine starch test.

Results

The average follow-up period was 12.8 months. Nineteen patients had a fair-to-good result and ten patients had poor results. The postoperative Minor's test demonstrated that there were remarkable improvements for patients with mild to moderate symptoms. Complications including superficial second degree burns (n=3) were treated in a conservative manner. A deep second degree burn (n=1) was treated by a surgical procedure.

Conclusions

Subcutaneous pulsed Nd-YAG laser has many advantages and is an effective noninvasive treatment for mild to moderate axillary osmidrosis.

Treatment options for hyperhidrosis

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

Primary focal hyperhidrosis: current treatment options and a step-by-step approach

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).

Guidelines on surgery of the thoracic sympathetic nervous system

Thoracic sympathetic nervous system (TSNS) surgery has increased in importance in the last few years, generating great expectations among the general population and the scientific community. This has been due to the excellent results obtained by videothoracoscopy-assisted thoracic sympathectomy in the treatment of essential hyperhidrosis and other TSNS disorders. This minimally invasive surgical technique has been shown to be effective, and with a low morbidity it is accepted as one of the best therapeutic options for the treatment of palmar and bilateral axillary hyperhidrosis and the number of patients consulting with the intention of having the operation has increased considerably. Although compensatory sweating, which is occasionally intense, often occurs after the surgery, this and other secondary effects of the technique are well tolerated by patients. The current evidence on TSNS and the treatment of essential hyperhidrosis is based on observational studies, making it difficult to compare series and draw conclusions. There has been much discussion on standardising the technique, defining the most favourable levels for clipping, and choosing the type of denervation with least secondary effects. This has led to the need to draw up these guidelines which should clarify and standardise the criteria for managing patients with disorders of TSNS.

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.

Treatment of axillary hyperhidrosis/bromidrosis using VASER ultrasound

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Video-assisted thoracic sympathectomy in the treatment of primary hyperhidrosis: a retrospective study of 521 cases comparing different levels of ablation

OBJECTIVE

To compare different levels of ablation in terms of the degree of patient satisfaction and extent of postoperative reflex sweating in sympathectomized patients.

METHODS

A retrospective study involving 521 patients with primary hyperhidrosis, submitted to thoracic sympathectomy at the Monte Sinai Hospital and University Hospital of the Federal University of Juiz de Fora, from January of 2001 to December 2005. All patients were submitted to thermal ablation of the sympathetic stem and were divided into three groups: up to T2 (group I, n = 162); up to T3 (group II, n = 65); and up to T4 (group III, n = 294).

RESULTS

Optimal postoperative control of palmar/axillary hyperhidrosis was achieved in, respectively, 94/82% of the patients of group I, 89/89% of those in group II and 80/80% of those in group III. Postoperative reflex sweating was observed in 67% of the patients in groups I and II, compared with 61.29% of those in group III. Severe reflex sweating occurred in 32% of the group I patients, 9% of the group II patients and 4% of the group III patients.

CONCLUSION

Sympathectomy provided excellent patient satisfaction and a low incidence of complications. There was no significant difference between the levels of ablation in terms of reflex sweating, although the intensity of this complication decreased when lower levels of blockage, principally at the T4 level, were employed.

Immunohistochemical Differentiation and Localization Analysis of Sweat Glands in the Adult Human Axilla

BACKGROUND

The classic concept of axillary glands differentiates between eccrine glands, producing abundant clear, nonodorous sweat; and apocrine glands, excreting small amounts of turbid, odorous milky sweat. A third type of sweat glands, the "apoeccrine" glands, were recently identified. To define the different types of sweat glands and their location and number, the authors carried out a prospective histologic study on adult human axillary skin, including various immunohistochemical markers.

METHODS

Forty-three consecutive Caucasian, subjectively normhidrotic patients, who underwent a surgical procedure in the axilla unrelated to the axillary glands, were included in the study. For verification of normhidrosis, the gravimetric test was carried out by measuring the amount of sweat secretion per minute. Then, a 1 x 1-cm measuring piece of skin and subcutaneous tissue was excised in the apex of the axilla, divided into three samples--altogether, 129 samples--and processed for histologic examination.

RESULTS

In the dermis, the authors found only very few eccrine (average, 0.3 gland/cm in only 12 percent of all patients) and apocrine glands (average, 0.1 gland/cm in only 4.7 percent of patients), and no apoeccrine glands in any patient. In the subcutaneous tissue, the mean number of glands per centimeter squared was 10 for the eccrine glands, nine for the apocrine glands, and six for the apoeccrine glands.

CONCLUSIONS

In the authors' Caucasian subjects, all or most of the sweat glands were found in the subcutaneous tissue near the border to the dermis and not in the dermis. For extremely hyperfunctioning sweat glands, the authors recommend less radical surgical methods, with the preservation of skin, based on the knowledge that most glands are localized in the subcutaneous tissue.

Daily pattern of sweating and response to stress and exercise in patients with palmar hyperhidrosis

BACKGROUND

Focal hyperhidrosis is an embarrassing condition that can have a significant negative impact on patient quality of life. It is characterized by excessive sweating affecting a variety of areas, including the palms. Little is known about the daily pattern of sweating in patients with palmar hyperhidrosis.

OBJECTIVES

To compare the variation of sweating in patients with primary palmar hyperhidrosis with healthy individuals during daily activities.

METHODS

Twenty patients with primary palmar hyperhidrosis and 20 healthy age- and sex-matched subjects were studied. Each participant self-assessed rates of sweating for 7 days on an hourly basis using a subjective evaluation scale (SES) ranging from 0 to 10.

RESULTS

The 3763 assessments showed clear differences between patients and healthy controls (median SES score 5 and 0, respectively; P < 0.0001). Stress and exercise significantly increased SES by scores of 2-5 in both groups, with stress influencing patients more than controls. SES scores in patients varied significantly, from 0 to 2 during mornings and evenings, and between 5 and 6 at mid-day, while scores in control subjects remained consistently close to 0. The pattern of change depended weakly on sex and weekday/weekend distinction. Dynamic responses to stress and exercise in patients had the tendency to return to baseline more slowly than in controls.

CONCLUSIONS

Hourly changes in sweating rates can be assessed successfully through self-assessment. Patients with primary palmar focal hyperhidrosis reported significantly increased palmar sweating and daily patterns of sweating showing considerable variation dependent on factors such as time of day and emotional stimuli.

Liposuction for axillary hyperhidrosis

Excessive axillary sweating is a common problem for which many patients frequently seek dermatological advice. The removal of axillary sweat glands using liposuction with tumescent anaesthesia in an outpatient setting is a relatively short and simple procedure with few complications, as seen in this case series. We present 10 patients treated with axillary liposuction under tumescent anaesthesia. Of the 10 patients treated, four relapsed with axillary hyperhidrosis and required additional liposuction to the same area. The longest time to relapse was 15 months, with 4 months being the shortest time. Six patients have not required additional liposuction, with 7 years being the longest time of remission. The complications reported were bruising in the axillae of two patients and relapse of hyperhidrosis in four patients.

Hyperhidrosis: evolving therapies for a well-established phenomenon

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

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.

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.

Treatment of hyperhidrosis and drooling with botulinum exotoxin

The treatment of focal hyperhidrosis and drooling with neurolysis of the neuroglandular junction is a relatively new and useful technique for managing such obvious conditions and improving the patient's quality of life. The treatment is safe, minimally invasive, and an effective alternative to other treatment modalities.

Effect of botulinum toxin type A on quality of life measures in patients with excessive axillary sweating: a randomized controlled trial

BACKGROUND

Botulinum toxin type A (BTX-A) has been shown to be a safe and effective treatment for primary focal hyperhidrosis. However, the effect of BTX-A therapy on quality of life (QOL) in patients with this condition has only recently begun to be studied in controlled clinical trials.

OBJECTIVES

To assess the impact on QOL of BTX-A treatment in patients with bilateral primary axillary hyperhidrosis.

METHODS

A multicentre, randomized, double-blind, placebo-controlled trial enrolled 320 patients who exhibited persistent, bilateral, primary axillary hyperhidrosis sufficient to interfere with daily activities. These patients were treated with either 50 U BTX-A (Botox, Allergan, Inc., Irvine, CA, U.S.A.) or placebo in each axilla. QOL was assessed using the Hyperhidrosis Impact Questionnaire (HHIQ) at baseline and 1, 4, 8, 12 and 16 weeks post-treatment, as well as the Medical Outcomes Trust Short Form-12 Health Survey(SF-12) at baseline and 16 weeks post-treatment.

RESULTS

At baseline, participants reported a marked negative impact of hyperhidrosis on various measures, including emotional status, ability to participate in daily and social activities, productivity at work and number of clothing changes per day. During the post-treatment period, statistically and clinically significantly greater improvements in all of these parameters were observed for the BTX-A group compared with the placebo group (P < 0.01). The BTX-A group improvements were observed within 1 week of treatment, and were sustained with little or no decline throughout the 16-week follow-up period. Compared with the baseline HHIQ responses regarding treatment history, BTX-A treatment resulted in a greater level of overall treatment satisfaction than did many other hyperhidrosis treatments. In addition, patients treated with BTX-A exhibited statistically significantly greater improvement in the physical component summary score of the SF-12 at 16 weeks than did placebo-treated patients (P < or = 0.019).

CONCLUSIONS

Hyperhidrosis is associated with a substantial QOL burden; however, QOL is markedly improved with BTX-A treatment.

Long-term quantitative benefits of botulinum toxin type A in the treatment of axillary hyperhidrosis

BACKGROUND

Although axillary hyperhidrosis is readily treated with botulinum toxin, the time course of benefits is not well established.

OBJECTIVE

To quantify the long-term effectiveness of botulinum toxin type A (BTX-A) for the treatment of axillary hyperhidrosis.

METHODS

This was a double-blind, placebo-controlled study. Eighteen patients received intradermal injections of either 100 U BTX-A (50 U/ml/axilla) or placebo. Sweating per surface area was quantified monthly for 5 months.

RESULTS

The BTX-A group had an average reduction in sweat production of 91.6% at 2 weeks (from 5.03 ml/min/m(2) to 0.42 ml/min/m(2), P <.05). The average reduction over 5 months was 88.2%. At the end of the study, only 1 of 12 BTX-A-treated patients had returned to baseline sweat production.

CONCLUSION

These quantitative results demonstrate that BTX-A is a safe and effective treatment for axillary hyperhidrosis and that the benefits last for at least 5 months.

Long-term efficacy and quality of life in the treatment of focal hyperhidrosis with botulinum toxin A

BACKGROUND

Botulinum toxin A has been used increasingly in the treatment of focal hyperhidrosis.

OBJECTIVE

To assess the long-term efficacy of botulinum toxin A in the treatment of hyperhidrosis and the changes in quality of life and patient satisfaction with treatment.

METHODS

A questionnaire was designed to assess the efficacy using visual analog scales and the quality of life both before and after treatment using a modified Dermatology Life Quality Index scale.

RESULTS

There was a reduction in the hyperhidrosis and a statistically significant improvement in the quality of life scores for the axillae, palms, and forehead.

CONCLUSION

Botulinum toxin A injections are safe and effective for the treatment of hyperhidrosis of the axillae, palms, and forehead, resulting in an improved quality of life for patients.

Axillary osmidrosis treated by partial removal of the skin and subcutaneous tissue en bloc and apocrine gland subcision

BACKGROUND

Axillary osmidrosis can be treated with many methods, but local surgery is the treatment of choice.

METHODS

Forty-three patients (32 females and 11 males, average age 20.3 years) were treated by partial removal of the skin and subcutaneous tissue en bloc and follicular clipping of the adjacent area. All operations were performed with local anesthesia in an outpatient setting.

RESULTS

Follow-up ranged from 2 to 47 months (mean: 13.4 months). Forty-one patients (95%) had good results, two (5%) were fair, and none were poor. No recurrences were seen. The wound complication rate was 3.5% for axillae and 7% for patients. There were no scar contractures or limitations of arm abduction.

CONCLUSION

This combined surgical method can eliminate malodor and has a low wound complication and recurrence rate. Though the transient and conspicuous scar is the chief drawback of this method, it is a simple, safe, effective and inexpensive method for treating axillary osmidrosis.

Treatment of palmar hyperhidrosis with botulinum toxin

Excessive sweating of the palms, axillae, and soles can be managed with intradermal injections of botulinum toxin as an alternative to more aggressive surgical therapies such as sympathectomy and less effective techniques including topical antiperspirants. The dosage and injection techniques can be optimized to provide several months of freedom from this troubling disorder.