A new device for the treatment of hyperhidrosis by iontophoresis

Pathological Changes in Axillary Hyperhidrosis and Axillary Osmidrosis Induced by Microwave Treatment: Comparison of Single- and Double-Pass Irradiation

BACKGROUND AND OBJECTIVES

To analyze histopathological changes and degree of damage to the axillary tissue due to single- and double-pass irradiation therapy using a microwave energy-based device. STUDY DESIGN/MATERIALS AND METHODS: We included 15 axillary hyperhidrosis and axillary osmidrosis patients who received microwave irradiation therapy between March 2017 and March 2019. Ten patients underwent single-pass irradiation and five underwent double-pass irradiation, after which skin samples were collected from the right and left axillae for pathological analysis. Samples were taken in a consistent manner from Patient 6 onwards and a comparative study of five single-pass and five double-pass patients was conducted (n = 10).

RESULTS

Histopathological analysis showed destruction and fibrosis in addition to necrosis and damage to the adipose tissue in apocrine and eccrine sweat glands. In the superficial microvasculature, blood vessel wall damage and thrombus formation were observed as well as damage in the hair follicles and hair bulbs. No obvious damage was observed in the epidermis and nerves. The amount of damage to sweat glands was higher in patients undergoing double-pass instead of single-pass irradiation.

CONCLUSION

From a histopathological point of view, microwave energy-based irradiation therapy can be considered efficient, as there was no damage to epidermis and nerves and favorable destruction of apocrine and eccrine glands. As the amount of damaged sweat glands was higher after double-pass irradiation, it can be considered more effective than single-pass irradiation. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Iontophoresis with glycopyrrolate for the treatment of palmoplantar hyperhidrosis

To determine the comparative efficacy of tap water iontophoresis to iontophoresis with the anticholinergic glycopyrrolate, we undertook a single-blinded right-left comparison study in 20 patients with palmoplantar hyperhidrosis. Most patients had their palms treated and one patient had the soles treated. We compared the duration of symptom relief following iontophoresis with glycopyrrolate unilaterally to iontophoresis with glycopyrrolate bilaterally. Patients filled in daily efficacy assessment cards. Each palm was rated as 'dry', 'slightly wet', 'moderately wet' or 'very wet'. Following treatment with unilateral tap water iontophoresis, unilateral glycopyrrolate and bilateral glycopyrrolate, patients reported hand dryness for a median of 3, 5 and 11 days, respectively. As the data was paired, treatment differences were analysed using a sign-rank test. Bilateral glycopyrrolate was superior to both unilateral glycopyrrolate and tap water in most patients. Unilateral glycopyrrolate was superior to tap water in most patients. All differences between groups were found to be statistically significant. We postulate that the increased efficacy of bilateral glycopyrrolate when compared with unilateral glycopyrrolate relates to its systemic absorption. We conclude that glycopyrrolate iontophoresis is more effective than tap water iontophoresis in the treatment of palmoplantar hyperhidrosis and that glycopyrrolate iontophoresis has both local and systemic effects on perspiration.

Placebo-controlled evaluation of direct electrical current administration for palmoplantar hyperhidrosis

BACKGROUND

Direct electrical current (d.c.) administration based on tap water iontophoresis has been used as a therapeutic option for palmoplantar hyperhidrosis. The placebo effect of this technique has not been investigated adequately.

AIM

To investigate whether d.c. administration has a possible placebo effect in the treatment of palmoplantar hyperhidrosis.

METHODS

As a placebo, low alternating electrical current (a.c.; 9-12 mA, 10-15 V, and 8-10 Hz) was applied to the palms of 15 patients with idiopathic palmoplantar hyperhidrosis. The placebo effect was evaluated by inspection and sweat intensity measurements performed before and after placebo application. Patients then received d.c. treatment (18-22 mA, 40-60 V) according to the same procedure as applied for placebo. The final sweat intensity measurements of the patients were performed 1 week after the last session of d.c. treatment. Sweat intensities measured before and after placebo and at the end of d.c. treatment were analyzed statistically by paired t-test.

RESULTS

The initial sweat intensity measurements of the palms, before placebo application, were 3.12 +/- 0.39 g/h on the right side and 3.17 +/- 0.28 g/h on the left side. The second sweat intensity measurements, 1 week after the last session of placebo, were 3.08 +/- 0.46 g/h on the right side and 3.16 +/- 0.21 g/h on the left side. There were no significant differences between the initial and second sets of sweat intensity measurements of the hands (P > 0.05 for both sides). The final sweat intensity measurements, 1 week after the last session of d.c. treatment, were 0.38 +/- 0.06 g/h on the right side and 0.39 +/- 0.07 g/h on the left side.

CONCLUSIONS

Statistical evaluation of sweat intensity measurements and inspections revealed that d.c. administration had no placebo effect in the treatment of palmoplantar hyperhidrosis.

Randomisierte, plazebokontrollierte klinische Doppelblindstudie zur Wirksamkeit und Vertraglichkeit der oralen Therapie mit Methantheliniumbromid (VagantinR) bei fokaler Hyperhidrose. Randomized, placebo-controlled, double blind clinical trial for the evaluation of the efficacy and safety of oral methantheliniumbromide (VagantinR) in the treatment of focal hyperhidrosis

BACKGROUND

Methanthelinium bromide is a quaternary ammonium derivate with anticholinergic activity. Since 1951 it has been used to treat patients with hyperhidrosis. However, all efficacy data has so far been limited to case reports and case series. We here report on the results of the first randomised clinical controlled trial on the efficacy and safety of methanthelinium bromide.

PATIENTS AND METHODS

A total of 41 patients with a mean age (+/- standard deviation) of 28 +/- 9.8 years (Range 18.7-54.8) were included, 31 (76%) of them were females. Main inclusion criteria were are focal hyperhidrosis of a one year or longer duration and a gravimetrically assessed sweat production of > or =50 mg/min. Patients were treated with 2 x 50 mg methanthelinium bromide or placebo orally daily for 4 weeks. The therapeutic effect was determined by repeated gravimetric measurement of sweat production and by recording the patients' degree of satisfaction.

RESULTS

The efficacy was most pronounced for patients with an axillary hyperhidrosis of > or =50 mg/min (p = 0.02, chi2-test, two-sided). For the total group the main axillary sweat production decreased in the verum-treated arm from a mean value of 89.2 +/- 73.4 mg/min prior to therapy to 53.3 +/- 48.7 mg/min during therapy (p = 0.02, Wilcoxon test, two-sided). In contrast, no difference was detected in the placebo arm with 60.7 +/- 42.8 mg/min prior to and 59.1 +/- 40.6 mg/min during therapy (p = 0.92, Wilcoxon test, two-sided). For the palmar sweat production no difference between the verum- and the placebo-treated group was found. No serious adverse events were reported. As expected, dryness of the mouth, a known adverse reaction of anticholinergics, was reported significantly more frequently in the verum-treated arm.

CONCLUSIONS

Methanthelinium bromide has been considered for many years as a therapeutic option for the treatment of focal hyperhidrosis. However, its efficacy and safety have not previously been investigated in controlled randomised studies. We demonstrated both a decline in axillary sweat production and good tolerance. Therefore, the treatment of axillary hyperhidrosis with methanthelinium bromide in a regimen of 50 mg twice daily can be recommended, especially in those cases which are refractory to topical treatment with for example aluminium chloride hexahydrate solution. In contrast, we found no evidence for a clinically relevant diminution of palmar sweating.

Management of primary hyperhidrosis: a summary of the different treatment modalities

Hyperhidrosis is a common and distressing condition involving increased production of sweat. A variety of treatment modalities are used to try to control or reduce sweating. Sweat is secreted by eccrine glands innervated by cholinergic fibers from the sympathetic nervous system. Primary hyperhidrosis most commonly affects palms, axillae and soles. Secondary hyperhidrosis is caused by an underlying condition, and treatment involves the removal or control of this condition. The treatment options for primary hyperhidrosis involve a range of topical or systemic medications, psychotherapy and surgical or non-surgical invasive techniques. Topical antiperspirants are quick and easy to apply but they can cause skin irritation and have a short half life. Systemic medications, in particular anticholinergics, reduce sweating but the dose required to control sweating can cause significant adverse effects, thus, limiting the medications' effectiveness. Iontophoresis is a simple and well tolerated method for the treatment of hyperhidrosis without long-term adverse effects; however, long-term maintenance treatments are required to keep patients symptom free. Botulinum toxin A has emerged as a treatment for hyperhidrosis over the past 5-6 years with studies showing good results. Unfortunately, botulinum toxin A is not a permanent solution, and patients require repeat injections every 6-8 months to maintain benefits. Psychotherapy has been beneficial in a small number of cases. Percutaneous computed tomography-guided phenol sympathicolysis achieved good results but has a high long-term failure rate. Surgery has also been shown to successfully reduce hyperhidrosis but, like other therapies, has several complications and patients need to be informed of these prior to undergoing surgery. The excision of axillary sweat glands can cause unsightly scarring and transthoracic sympathectomy (either open or endoscopic) can be associated with complications of compensatory and gustatory hyperhidrosis, Horner syndrome and neuralgia, some of which patients may find worse than the condition itself.

Fabry disease: recognition and management of cutaneous manifestations

Fabry disease (angiokeratoma corporis diffusum universale) is a rare, X chromosome-linked lysosomal storage disease. The deficient enzyme, alpha-galactosidase A (alpha-gal A), is responsible for the accumulation of neutral glycosphingolipids within vascular endothelial lysosomes of various organs, including skin, kidneys, heart, and brain. The disease manifests primarily in affected hemizygous men and to some extent in heterozygous women ('carriers'). The diagnosis of Fabry disease is made in hemizygous males after the detection of the presence of angiokeratomas, irregularities in sweating, edema, scant body hair, painful sensations, and of cardiovascular, gastrointestinal, renal, ophthalmologic, phlebologic, and respiratory involvement. A deficiency of alpha-gal A in serum, leukocytes, tears, tissue specimens, or cultured skin fibroblasts further supports the diagnosis in male patients. Since heterozygous women show angiokeratomas in only about 30% of cases and may have alpha-gal A levels within normal range, genetic analysis is recommended. Current treatment of angiokeratomas of Fabry disease is based mainly on the use of laser systems, including variable pulse width 532nm Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser, 578nm copper vapor laser, and flashlamp-pumped dye laser. When cutaneous and mucous glands are affected, restrictions may be required with regard to the time spent in a warm climate and the amount time spent working or on sporting activities, and may necessitate the use of topical and systemic antiperspirant agents, and topical application of artificial lacrimal fluid and saliva, respectively. For the future, new treatment modalities, including enzyme replacement therapy, substrate deprivation strategies, and gene therapy offer extraordinary options for the cutaneous and visceral lesions in patients with Fabry disease.

Safe control of palmoplantar hyperhidrosis with direct electrical current

BACKGROUND

Primary (idiopathic) hyperhidrosis is a benign disease of unknown etiology, leading to the disruption of professional and social life and emotional problems. A variety of treatment methods have been used to control or reduce the profuse sweating. In this study, we report the efficacy of direct current (d.c.) administration in the treatment of idiopathic hyperhidrosis.

METHODS

One hundred and twelve patients with idiopathic hyperhidrosis were enrolled in the study. Initial sweat intensities of the palms were measured by means of the pad glove method. The patients were treated in eight sessions with d.c. administration using a complete regulated d.c. unit based on tap water iontophoresis. The final sweat intensities of responders were determined 20 days after the last treatment. Nonresponders returned earlier than 20 days, with final sweat intensities measured at least 5 days after the last treatment. In 26 responders, plantar hyperhidrosis was also treated. After the first remission period, the second of eight treatments was applied to the palms of 37 responders.

RESULTS

This therapy controlled palmar hyperhidrosis in 81.2% of cases. The final sweat intensities of the palms of responders were significantly reduced after eight treatments (P < 0.001). The first average remission period was 35 days. Minimal undesirable effects were noted.

CONCLUSIONS

This technique appears to control hyperhidrosis on the palms and soles only if regular treatment is applied. Plantar hyperhidrosis appeared to resolve simultaneously when palmar hyperhidrosis was successfully treated.

Palmar hyperhidrosis: evidence of genetic transmission

BACKGROUND

Primary palmar hyperhidrosis is a condition marked by excessive perspiration and is reported to have an incidence of 1% in the Western population. It is a potentially disabling disorder that interferes with social, psychological, and professional activities. Over the past several years, several investigators have reported a positive family history in their patients treated for hyperhidrosis. To date, the cause is unknown; furthermore, epidemiologic data are scarce and inadequate.

METHODS

To characterize the genetic contribution to hyperhidrosis, we conducted a prospective study of 58 consecutive patients with palmar, plantar, or axillary hyperhidrosis treated with thoracoscopic sympathectomy from September 1993 to July 1999. Forty-nine of the 58 probands volunteered family history data for these analyses (84% response rate). A standardized questionnaire was administered during the postoperative visit or by phone interview, and a detailed family history was obtained. The same questionnaire was also administered to a set of 20 control patients. The familial aggregation of hyperhidrosis has been quantified by estimating the recurrence risks to the offspring, parents, siblings, aunts, uncles, and cousins of 49 probands and 20 controls. We estimated the penetrance by use of a genetic analysis program.

RESULTS

Thirty-two of 49 (65%) reported a positive family history in our hyperhidrosis group, and 0% reported a positive family history in our control group. A recurrence risk of 0.28 in the offspring of probands compared with frequency of 0.01 in the general population provides strong evidence for vertical transmission of this disorder in pedigrees and is further supported by the 0.14 risk to the parents of the probands. The results indicate that the disease allele is present in about 5% of the population and that one or two copies of the allele will result in hyperhidrosis 25% of the time, whereas the normal allele will result in hyperhidrosis less than 1% of the time.

CONCLUSIONS

We conclude that primary palmar hyperhidrosis is a hereditary disorder, with variable penetrance and no proof of sex-linked transmission. However, this does not exclude other possible causes, and we anticipate that genetic confirmation of this disorder may lead to earlier diagnoses and advances in medical and psychosocial interventions.

The treatment of primary palmar hyperhidrosis: a review

Primary palmar hyperhidrosis (HH) is a pathological condition of overperspiration caused by excessive secretion of the eccrine sweat glands, the etiology of which is unknown. This disorder affects a small but significant proportion of the young population all over the world. Neither systemic nor topical drugs have been found to satisfactorily alleviate the symptoms. Although the topical injection of botulinum has recently been reported to reduce the amount of local perspiration, long-term results are required before a definitive evaluation of this method can be made. Hypnosis, psychotherapy, and biofeedback have been beneficial in a limited-number of cases. While radiation achieves atrophy of the sweat glands, its detrimental effects prohibit its use. Iontophoresis has attained some satisfactory results but it has not been assessed long term. Percutaneous computed tomography-guided phenol sympathicolysis achieves excellent immediate results, but its long-term failure rate is prohibitive. Furthermore, percutaneous radiofrequency sympathicolysis may be an effective procedure, but its long-term results are not superior to surgical sympathectomy. On the other hand, surgical upper dorsal (T2-T3) sympathectomy achieves excellent long-term results and the thoracoscopic approach has supplanted the open procedures. Despite some sequelae, mainly in the form of neuralgia and compensatory sweating which cannot be predicted and may be distressing, surgical sympathectomy remains the best treatment for palmar hyperhidrosis.

TREATMENT OF PALMOPLANTER HYPERHIDROSIS BY IONTOPHORESIS

Twenty-seven patients with idiopathic palmoplanter hyperhidrosis were treated with Iontotherapy over a one year period. In twenty-four cases there was a good response but maintenance therapy was required every 3-4 weeks.

Axillary Hyperhidrosis Treatment by Simple Skin Excision and Undermining

The current literature of axillary hyperhidrosis is reviewed. Excision of the gland-containing skin of the axilla has been a mainstay in the treatment of axillary hyperhidrosis for many years. A retrospective study was performed using data accumulated from 56 consecutive patients who underwent a surgical procedure modified from that originally described by Hurley and Shelley. Excision of the hair-bearing portion of the axilla with undermining of the adjacent skin and simple closure was performed under local or general anesthesia. Ninety-two per cent of patients were satisfied with the results. Five patients wished to undergo a second procedure, either because they still had excessive perspiration or because they were unhappy with their scars. Complication rates were low and were compared with other series. Thus, the described procedure provides a simple, safe and effective modality for the treatment of axillary hyperhidrosis.

Transthoracic endoscopic sympathectomy for primary palmar hyperhidrosis in children

Primary palmar hyperhidrosis often starts in childhood. It usually causes academic and social disabling at the age children begin primary school. This study included 65 children (44 girls and 21 boys, mean age 13.5 years) who underwent one-stage bilateral transthoracic endoscopic sympathectomy. The proper sympathetic segment was visualized in almost all cases and electrocautery ablation was performed. The immediate postoperative course was uneventful in all cases and no major morbidity was encountered. Horner's syndrome did not occur in any case. All patients were discharged the day of surgery or after an overnight stay. The duration of follow-up was from 6 months to 3 years. Although compensatory sweating was found in 40% of the patients, long-term satisfaction was reported in 63 cases (96%). This procedure is effective, simple, and is recommended as the method of choice for surgical treatment of severe upper extremity hyperhidrosis in children.

Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis

Endoscopic transthoracic electrocautery of the sympathetic chain has been the preferred treatment for palmar or axillary hyperhidrosis in this unit since 1980. A retrospective study was carried out of the first 112 patients with case material derived from a postal questionnaire, chart review and outpatient assessment. Eighty-five patients undergoing bilateral transthoracic electrocautery who replied to the questionnaire (76 per cent response rate) form the basis of this study. There were 65 females and 20 males with a mean age of 24.3 years (range 15-40 years). The hands alone were affected in 20 patients (24 per cent), the axillae alone in 17 (20 per cent) and both areas in 48 (56 per cent). Mean hospital stay was 3.1 days (range 1-7 days). Outcome was assessed by 92 per cent of patients immediately after operation as 'very much improved' or 'moderately improved', and this assessment persisted in 85 per cent after a mean follow-up of 43 months (range 3-95 months). Cosmetic results were rated as satisfactory by 95 per cent. Apart from pain after operation, morbidity was limited to transient Horner's syndrome in three patients, surgical emphysema in three, and pneumothorax requiring a chest drain in one. A repeat procedure was needed in one patient because of an inadequate first operation. Some compensatory hyperhidrosis occurred in 54 (64 per cent) patients. As a minimally invasive procedure, endoscopic transthoracic electrocautery should be considered the treatment of choice for palmar and axillary hyperhidrosis.

Biology of sweat glands and their disorders. II. Disorders of sweat gland function

Part I of this article (J Am Acad Dermatol 1989; 20:537-63) focused on normal sweat gland function. Part II provides a discussion of hyperhidrosis and hypohidrosis. Hyperhidrotic disorders affect the palms and soles and the axillae and are associated with previous spinal cord injuries, peripheral neuropathies, brain lesions, intrathoracic neoplasms, systemic illness, and gustatory sweating. Hypohidrotic disorders include anhidrotic ectodermal dysplasia, hereditary sensory neuropathy, Holmes-Adie syndrome, and generalized anhidrosis.

Efficacy of the Drionic unit in the treatment of hyperhidrosis

A portable iontophoretic device (the Drionic unit) has recently been introduced for the treatment of hyperhidrosis. Twenty-two patients with hyperhidrosis were treated at twenty-seven sites (axillae, palms, soles) with this unit. Sweat output was measured by use of Persprint paper and the data were quantified by an image analysis computer. The data clearly demonstrate the efficacy of the Drionic unit at all treatment locations in the great majority of subjects. One month posttreatment follow-up showed a statistically significant continued sweat inhibition at the palmar sites. Side effects were common, but none was severe enough to necessitate discontinuation of treatment. Based on the results of this study, we conclude that the Drionic unit appears to have a definite place in the treatment of hyperhidrosis.

Treatment of primary hyperhidrosis

Primary hyperhidrosis is a physically and emotionally distressing condition. Physicians should be aware of the various treatment modalities available for controlling or reducing the profuse sweating, which involves mainly the palms, soles, and axillas. The simplest methods, such as topical application of aluminum chloride, should be attempted first. If topical medications are ineffective, iontophoresis may provide relief, especially in patients with plantar or palmar involvement. When patients are unresponsive to other treatment options, surgical intervention may be warranted-excision of sweat glands in patients with axillary hyperhidrosis and upper thoracic sympathectomy in those with palmar involvement. Although excellent results have been reported, complications and resumption of sweating have occurred.