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Abdelshaheed M, Attallah H, El-Gilany AH, Bayoumy Youssef Y, Ahmed Sharaf E. Efficacy, safety and quality of life of oxybutynin versus aluminum chloride hexahydrate in treating primary palmar hyperhidrosis. Indian J Dermatol 2022; 67:222-227. [DOI: 10.4103/ijd.ijd_799_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Briatico G, Pampena R, Fulgione E, Babino G, Giorgio CM, D'Ambra I, Caccavale S, Longo C, Argenziano G. Real-life experience with oral oxybutynin long-term continuous therapy in severe hyperhidrosis and systematic review of the literature. Dermatol Ther 2021; 34:e14832. [PMID: 33527699 DOI: 10.1111/dth.14832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/28/2020] [Accepted: 01/23/2021] [Indexed: 11/28/2022]
Abstract
Hyperhidrosis is a disorder of excessive sweating severely impacting on patient's quality of life (Qol). Several studies have been published about oral oxybutynin, but no studies focused on the achievement of complete clinical and Qol response. The aim of this study was to report our real-life experience with oral oxybutynin in patients with severe hyperhidrosis significantly affecting their Qol. In this cohort retrospective study, we enrolled, in a 3-year period, patients affected by severe hyperhidrosis with poor Qol, continuously treated with oral oxybutynin. Our outcome was the obtainment of complete clinical and Qol improvement. A systematic review of the literature was also performed reporting efficacy and safety of oral oxybutynin for primary hyperhidrosis. We enrolled 62 patients, of which 53 (85.5%) received a mean daily dose of 10 mg and nine (15.5%) of 5 mg. Complete clinical response was achieved in 77.4% (48/62) of cases, while complete Qol improvement occurred in 51.6% (32/62) of cases. Adverse events were only reported as mild, with dry mouth being the most frequently observed (16.1%). Kaplan-Meier survival analysis highlighted that both median clinical and Qol complete responses were reached after 1 year of continuous therapy with oral oxybutynin. The main limitation of our study is the small number of patients enrolled. Long-term therapy with oral oxybutynin for severe hyperhidrosis, continuously administered at a mean daily dosage of 5 to 10 mg, allowed the majority of our patients to reach both clinical and Qol complete improvement, without significant adverse events.
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Affiliation(s)
- Giulia Briatico
- Dermatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Riccardo Pampena
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia, Reggio Emilia, Italy
| | | | - Graziella Babino
- Dermatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Ilenia D'Ambra
- Dermatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stefano Caccavale
- Dermatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Caterina Longo
- Centro Oncologico ad Alta Tecnologia Diagnostica, Azienda Unità Sanitaria Locale-Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia, Reggio Emilia, Italy.,Dermatology Unit, University of Modena and Reggio Emilia, Reggio Emilia, Italy
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3
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Kamikava DYF, Wolosker N, da Silva MFA, de Campos JRM, Puech-Leão P. Symptoms of anxiety and depression in patients with primary hyperhidrosis and its association with the result of clinical treatment with oxybutynin. Clinics (Sao Paulo) 2021; 76:e2892. [PMID: 34190853 PMCID: PMC8221552 DOI: 10.6061/clinics/2021/e2892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Studies have identified correlations between the psychological characteristics of individuals with primary hyperhidrosis (HH), the degree of sweating, and the quality of life (QoL). This study aimed to evaluate the prevalence of anxiety and depression symptoms in patients with HH before and after oxybutynin treatment. METHODS Data were collected from 81 patients. Palmar or axillary HH was the most frequent complaint (84.0%). All patients were evaluated before the medication was prescribed and after five weeks of treatment. The Beck Depression Inventory and Beck Anxiety Inventory were used to evaluate depression and anxiety. RESULTS Improvement in HH occurred in 58 patients (71.6%), but there was no improvement in 23 patients (28.4%). The QoL before treatment in all patients was either "poor" or "very poor." Patients who experienced improvement in sweating rates also experienced a greater improvement in QoL than patients who did not experience improvement in sweating at the main site (87.9% vs. 34.7%) (p<0.001). A total of 19.7% of patients showed an improvement in their level of depression, and a total of 46.9% of patients exhibited improvements in their level of anxiety. A significant correlation was observed between sweating and anxiety (p=0.015). CONCLUSION Patients with HH who experienced improvements in sweating immediately after treatment with oxybutynin exhibited small improvements in their levels of depression and significant improvements in their levels of anxiety and QoL.
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Affiliation(s)
- Débora Yumi Ferreira Kamikava
- Divisao de Psicologia, Instituto Central, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Nelson Wolosker
- Disciplina de Cirurgia Vascular e Endovascular, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Hospital Israelita Albert Einstein, Sao Paulo, SP, BR
| | | | - José Ribas Milanez de Campos
- Hospital Israelita Albert Einstein, Sao Paulo, SP, BR
- Disciplina de Cirurgia Toracica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Pedro Puech-Leão
- Disciplina de Cirurgia Vascular e Endovascular, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Campanati A, Gregoriou S, Consales V, Rizzetto G, Bobyr I, Diotallevi F, Martina E, Kontochristopoulos G, Platsidaki E, Offidani A. Combined treatment of palmar hyperhidrosis with botulinum toxin type A and oxybutynin chloride: Results of a clinical, multicenter, prospective study. Dermatol Ther 2020; 33:e14039. [DOI: 10.1111/dth.14039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/07/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Anna Campanati
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
| | - Stamatios Gregoriou
- Faculty of Medicine, First Department of Dermatology Andreas Syggros Hospital, National and Kapodistrian University of Athens Athens Greece
| | - Veronica Consales
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
| | - Giulio Rizzetto
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
| | - Ivan Bobyr
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
| | - Federico Diotallevi
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
| | - Emanuela Martina
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
| | - George Kontochristopoulos
- Faculty of Medicine, First Department of Dermatology Andreas Syggros Hospital, National and Kapodistrian University of Athens Athens Greece
| | - Eftychia Platsidaki
- Faculty of Medicine, First Department of Dermatology Andreas Syggros Hospital, National and Kapodistrian University of Athens Athens Greece
| | - Annamaria Offidani
- Dermatological Unit, Department of Clinical and Molecular Sciences Polytechnic University of the Marche Region Ancona Italy
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5
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Soeberdt M, Kilic A, Abels C. Current and emerging treatments targeting the neuroendocrine system for disorders of the skin and its appendages. Exp Dermatol 2020; 29:801-813. [DOI: 10.1111/exd.14145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/09/2020] [Accepted: 06/25/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | - Ana Kilic
- Dr. August Wolff GmbH & Co. KG Arzneimittel Bielefeld Germany
| | - Christoph Abels
- Dr. August Wolff GmbH & Co. KG Arzneimittel Bielefeld Germany
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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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The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options. J Am Acad Dermatol 2019; 81:669-680. [PMID: 30710603 DOI: 10.1016/j.jaad.2018.11.066] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/11/2018] [Accepted: 11/14/2018] [Indexed: 11/21/2022]
Abstract
Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.
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Delort S, Marchi E, Corrêa MA. Oxybutynin as an alternative treatment for hyperhidrosis. An Bras Dermatol 2017; 92:217-220. [PMID: 28538882 PMCID: PMC5429108 DOI: 10.1590/abd1806-4841.201755126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 02/28/2016] [Indexed: 11/22/2022] Open
Abstract
Hyperhidrosis is the excessive production of sweating, which can be primary and focal or secondary to various pathologies. The exact cause of primary focal hyperhidrosis is still unknown, although a genetic basis is recognized, and its prevalence varies from 1% to 2.8%. The most affected sites are the armpits, palms, soles and face. It causes much discomfort, affects the quality of life, and is estimated to be undervalued by health professionals. Many treatment options are proposed, both clinical and surgical. The aim of this review is to focus on the treatment of hyperhidrosis with oxybutynin, an anticholinergic drug originally used to control overactive bladder.
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Affiliation(s)
- Sergio Delort
- Graduate program of the Faculdade de Medicina de Jundiaí (FMJ) - Jundiaí (SP), Brazil
| | - Evaldo Marchi
- Departament of Thoracic Surgery of the Faculdade de Medicina de Jundiaí (FMJ) - Jundiaí (SP), Brazil
| | - Marcos Antônio Corrêa
- Departament of Drugs and Medicines of the Universidade Estadual Paulista "Júlio de Mesquita Filho" (Unesp) - Botucatu (SP), Brazil
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Varella AYM, Fukuda JM, Teivelis MP, Campos JRMDE, Kauffman P, Cucato GG, Puech-Leão P, Wolosker N. Translation and validation of Hyperhidrosis Disease Severity Scale. Rev Assoc Med Bras (1992) 2017; 62:843-847. [PMID: 28001258 DOI: 10.1590/1806-9282.62.09.843] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 01/18/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction The evaluation of patients with hyperhidrosis (HH) can be accomplished, among other ways, through questionnaires and scales. The Hyperhidrosis Disease Severity Scale (HDSS) has been used as a simple and quick tool to perform this evaluation. Although HDSS has been well established in several languages, it has not been translated into Portuguese, restricting its specific use for Brazilian patients. The aim of this study was to translate HDSS into Portuguese and validate it in a sample of Brazilian subjects. Method 290 Brazilian patients (69% women, with a mean age of 28.7±9.6 years and BMI 22.4±3.9 kg/m2) diagnosed with HH were evaluated using HDSS, Quality of Life Questionnaire (QLQ) and Sweating Evolution Questionnaire (SEQ) before and after a five-week oxybutynin treatment. Regarding validation, an association between HDSS results and two other questionnaires was performed. To analyze HDSS sensitivity, evaluation of effects pre- and post-treatment with oxybutynin was conducted. Furthermore, HDSS reproducibility was analyzed in a subsample in which the scale was applied again after 7 days of the first follow-up appointment. Results There was statistical correlation between HDSS and QLQ and between HDSS and SEQ before treatment and after 5 weeks. Additionally, HDSS was reproducible and sensitive to clinical changes after the treatment period. Conclusion The Portuguese version of HDSS has been validated and shown to be reproducible in a Brazilian sample. Therefore it can be used as a tool to improve medical assistance in patients with HH.
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Affiliation(s)
| | - Juliana Maria Fukuda
- Vascular Surgery Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - José Ribas Milanez DE Campos
- Vascular Surgery Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Vascular Surgery Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Kauffman
- Vascular Surgery Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Vascular Surgery Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Gabriel Grizzo Cucato
- Vascular Surgery Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Pedro Puech-Leão
- Vascular Surgery Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nelson Wolosker
- Vascular Surgery Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.,Vascular Surgery Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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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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Abstract
Plantar hyperhidrosis, excessive sweating on the soles of feet, can have a significant impact on patients' quality of life and emotional well-being. Hyperhidrosis is divided into primary and secondary categories, depending on the cause of the sweating, with plantar hyperhidrosis typically being primary and idiopathic. There is an overall increased risk of cutaneous infection in the presence of hyperhidrosis, including fungal, bacterial, and viral infections. This article discusses a range of treatment options including topical aluminum chloride, iontophoresis, injectable botulinum toxin A, glycopyrrolate, oxybutynin, laser, and endoscopic lumbar sympathectomy. Lifestyle changes regarding hygiene, shoe gear, insoles, and socks are also discussed.
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Affiliation(s)
- Tracey C Vlahovic
- Department of Podiatric Medicine, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107, USA.
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Millán-Cayetano JF, del Boz J, Rivas-Ruiz F, Blázquez-Sánchez N, Hernández Ibáñez C, de Troya-Martín M. Oral oxybutynin for the treatment of hyperhidrosis: outcomes after one-year follow-up. Australas J Dermatol 2016; 58:e31-e35. [DOI: 10.1111/ajd.12473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
| | - Javier del Boz
- Department of Dermatology; Hospital Costa del Sol; Marbella Spain
| | - Francisco Rivas-Ruiz
- Research Unit; Hospital Costa del Sol; Marbella Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas; Marbella Spain
| | | | | | - Magdalena de Troya-Martín
- Department of Dermatology; Hospital Costa del Sol; Marbella Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas; Marbella Spain
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13
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