Botulinum toxin A versus microwave thermolysis for primary axillary hyperhidrosis: A randomized controlled trial

Background

Botulinum toxin A (BTX) and microwave thermolysis (MWT) represent 2 treatment modalities for axillary hyperhidrosis with different procedural and efficacy profiles.

Objective

To compare long-term outcomes following BTX vs MWT treatment of axillary hyperhidrosis.

Methods

A prospective, randomized, within-patient, controlled trial, treating axillary hyperhidrosis with contralateral BTX and MWT. Objective sweat measurement and patient-reported outcome measures for sweat and odor were collected at baseline, 6-month and 1-year follow-up (6M/1YFU). Hair reduction and patient treatment preference was also assessed.

Results

Sweat reduction was significant (all P <.01) for both interventions throughout the study. Objectively, sweat reduction was equal at 1-year FU (ΔP =.4282), but greater for BTX than MWT at 6-month FU (ΔP =.0053). Subjective sweat assessment presented comparable efficacy (6MFU: ΔP =.4142, 1YFU: ΔP =.1025). Odor reduction was significant (all P <.01) following both interventions, whereas only sustaining for MWT (6MFU: ΔP =.6826, 1YFU: ΔP =.0098). Long-term, hair reduction was visible after MWT, but not BTX (ΔP ≤.0001), and MWT was preferred by the majority of patients (76%).

Limitations

The intrinsic challenges in efficacy assessment.

Conclusion

This study exhibited BTX and MWT with similar sweat reduction, but distinguishable odor and hair reduction at 1-year FU. These findings support individualized treatment approaches for axillary hyperhidrosis based on patient-specific symptoms and preferences.

New developments in cosmetic applications of electromagnetic fields: Client and occupational hazard assessment

Energy-based devices are used to improve features of appearance for aesthetic reasons while avoiding more invasive methods. Examples of treatment targets are the reduction of wrinkles, sagging, unwanted skin lesions, body hair and excess fatty tissue, and the enhancement of muscle tissue. One treatment modality is the use of electromagnetic fields (EMF, 0‒300 GHz). The present work aims to give an up-to-date survey of cosmetic applications of EMF for professional use with an assessment of client and worker exposure and possible adverse effects. A systematic search was conducted for peer-reviewed articles (2007-2022), patents, premarket notifications, manufacturer data, and adverse effects reports. Five categories of cosmetic EMF device with increasing frequency were identified: sinusoid low frequency magnetic fields for lipolysis; pulsed low frequency magnetic fields for skin rejuvenation; pulsed low frequency magnetic fields for muscle building; radiofrequency EMF for lipolysis or skin rejuvenation; microwaves for hair removal or hyperhidrosis. In the vicinity of the last four device categories, there is a potential for exceeding the occupational exposure limits in the European Union EMF Directive, which could lead to nerve or muscle stimulation, burns or overheating. There are also potential hazards for clients or workers wearing active or passive medical devices. The severity of reported adverse effects increases with EMF frequency.

The application of microwaves in axillary hyperhidrosis: Curative effect observation of a pathological examination over 1 year

BACKGROUND

In Asia, axillary hyperhidrosis is a frequent problem for many people, and the consequent excessive sweating can seriously affect many aspects of daily life and even lead to mental disorders. Microwave therapy is a new, non-invasive treatment method for axillary hyperhidrosis, whose energy and long-term effectiveness still needs to be clinically validated.

OBJECTIVE

The aim of this study was to evaluate the clinical efficacy, safety, histological changes, and psychological status of microwave devices in the treatment of axillary hyperhidrosis and osmidrosis.

METHOD

We conducted a prospective self-controlled study in a top-tier Chinese hospital. After a 5/5 energy treatment session, a skin biopsy was taken to observe histological changes both before and after treatment. An iodine starch test was used to determine the sweating range. We evaluated symptoms of improved efficacy using the Hyperhidrosis Disease Severity Scale (HDSS) and assessed changes in life status with the DLQI. In the case of concurrent underarm odor, odor-5, VAS, and Young-Jin Park grading were used to assess odor relief. The effect of odor on psychology was assessed by using a psychological status symptom checklist (scl-90). The study period was 1 year.

RESULTS

We observed 20 patients in this study. Of those, 90% met the primary treatment endpoint of a decrease in axillary hyperhidrosis symptomatology to below grade 2 on the HDSS score (p < 0.001). Furthermore, 75% of patients achieved a treatment endpoint of at least 50% reduction in VAS (p < 0.001). 70% of patients achieved a treatment endpoint of at least 50% reduction in odor-5 (p < 0.001). The iodine starch test showed that the region decreased 99% from the baseline to 12 months after follow-up had ended (p < 0.001). Eight patients volunteered to undergo histological examination; their average light density of immunohistochemistry decreased from 1.04 (0.4-2.11) to 0.07 (0.04-0.46; p < 0.05). The immunohistochemical positive number for sweat glands was initially 104 (59.75-132.5) but was 41.5 (29.75-62) after the procedure. None of the patients experienced any serious adverse reactions.

CONCLUSION

The treatment demonstrated high effectiveness, safety, and short-lived adverse reactions.

Attempted treatment of primary axillary hyperhidrosis with one session of either Neodymium YAG laser or Intense Pulsed Light: A within patient randomized trial of treated versus untreated contralateral axilla

BACKGROUND

Primary axillary hyperhidrosis (PAH) affects 1-5% of the world's population who has an unmet need for improved treatments. The heating of sweat glands with specific microwave therapy has shown promising results, yet, treatment with widely available devices such as long-pulsed Neodymium Yttrium Aluminum Garnet (Nd:YAG) lasers, diode lasers or Intense Pulsed Light (IPL) may serve as pragmatic alternatives.

OBJECTIVES

To compare sweat secretion of treated versus untreated contralateral control axilla 1-3 months after one session of Nd:YAG laser or IPL in patients with PAH.

METHODS

A within-person randomized controlled trial. Patients were randomized to receive either one session of Nd:YAG laser or IPL in one axilla with the contra-lateral serving as control. Sweat production was assessed by gravimetry, trans-epidermal water loss, hyperhidrosis disease severity scale and dynamic optical coherence tomography. Mixed-effects models were used to handle the within-person design, containing both fixed effect factors (side, group, and subgroup), and random effects (patients), while also adjusting for the level at baseline.

RESULTS

A total of 20 patients were enrolled. At follow-up 1-3 months after treatment, sweat secretion was not affected in the treated axilla when compared to the control axillae (0.01 [95%CI: -0.04 to 0.05]; p = 0.68). In the Nd:YAG subgroup (10 patients), least squares means for sweat secretion was 0.18 mg/5 min in the treated versus 0.15 mg/5 min in the control axilla, respectively, corresponding to a statistically insignificant mean difference of 0.02 mg/5 min (95% CI: -0.06 to 0.11; p = 0.54). In the IPL subgroup (10 patients), sweat secretion was 0.06 mg/5 min in the treated axilla versus 0.07 mg/5 min in the control axilla with a statistically insignificant difference of -0.01 points (95% CI: -0.03 to 0.02; p = 0.46). Likewise, none of the secondary outcomes were significantly affected by treatment. However, both treatments appeared safe and well tolerated with no adverse effects reported at follow-up.

CONCLUSIONS

One treatment with external 1064 nm Nd:YAG laser or 640 nm IPL at commercially available settings, failed to demonstrate clinical benefit in treating PAH, with narrow confidence intervals implying that this was not due to a type-2 error.

Treatment of hyperhidrosis with Botox (onabotulinumtoxinA): Development, insights, and impact

Hyperhidrosis (chronic excessive sweating) may substantially affect an individual's emotional and social well-being. Therapies available before onabotulinumtoxinA were generally topical, with limited effectiveness, application-site skin reactions, and frequent, time-consuming treatments. Intradermal injection of onabotulinumtoxinA to treat sweat glands arose as a novel therapeutic approach. To develop this treatment, appropriate dosing needed to be established, and training on administration was required. Further, no previous scale existed to measure the effects of hyperhidrosis on patients' lives, leading Allergan to develop and validate the 4-point Hyperhidrosis Disease Severity Scale (HDSS), which measures the disease's impact on daily activities. The onabotulinumtoxinA clinical development program for hyperhidrosis included 2 double-blind, placebo-controlled pivotal trials, immunogenicity studies, long-term studies of safety and efficacy, and quality of life assessments. In Europe and North America, the primary efficacy measures were, respectively, axillary sweat production measured gravimetrically and HDSS improvement. Compared with placebo, onabotulinumtoxinA treatment significantly reduced axillary sweat production and axillary hyperhidrosis severity, as measured by a 2-point or greater reduction on the HDSS. The effects of onabotulinumtoxinA occurred rapidly, within 1 week after injection, and lasted ≥6 months. Treatment with onabotulinumtoxinA was associated with significant quality of life improvements based on Short Form-12 physical and mental component scores. The Hyperhidrosis Impact Questionnaire also indicated greater treatment satisfaction, reduced negative impact on aspects of daily life, and improved emotional well-being with onabotulinumtoxinA versus placebo. The clinical development program and subsequent clinical experience showed that onabotulinumtoxinA treatment for hyperhidrosis was well tolerated with no new safety signals, and led to greater disease awareness.

Impact of microwave thermolysis energy levels on patient-reported outcomes for axillary hyperhidrosis and osmidrosis

OBJECTIVE

Microwave thermolysis (MWT) is an emerging treatment for axillary hyperhidrosis reducing both sweat and odor. No prior studies have investigated and compared the different available energy settings of the MWT device. This study evaluated patient-reported outcome measures (PROMs) for axillary hyperhidrosis and osmidrosis following MWT treatment with two different energy levels.

METHODS

Twenty adults with axillary hyperhidrosis and osmidrosis reported sweat on Hyperhidrosis Disease Severity scale (HDSS: 1-4) and odor on Odor scale (OS: 1-10), respectively, supplemented by overall Dermatology Life Quality Index (DLQI: 0-30). This was a prospective, randomized, patient-blinded and intraindividually controlled study with 3 months follow-up (FU). Randomization comprised MWT treatment of one axilla with a standard medium energy setting (energy level 3) and the contralateral axilla with a standard high energy setting (energy level 5).

RESULTS

At baseline, patients reported substantial sweat and odor, negatively affecting their quality of life. At 3 months FU, PROMs showed improved quality of life with significantly reduced odor and sweat. Overall DLQI was reduced from a median of 10 to 4, with a median 6.5-point reduction (p = 0.0002). HDSS was reduced from a median of 4 to 2 on both sides, with a median reduction of 1 for medium energy level and 2 points for high energy level (p = 0.014). OS was reduced from a median of 8 to 3 for both energy levels, with a median reduction of 3.5 and 4.5 points for the medium and high energy level, respectively (p = 0.017). Local skin reactions were mild and transient, but slightly more pronounced following treatment with the high energy level.

CONCLUSION

MWT effectively improved patients' quality of life, axillary sweat, and odor 3 months after on baseline treatment. Treatment with the high energy level presented a subtle but significant increase of efficacy based on PROMs for both sweat and odor. Patients were willing to accept a higher amount of temporary local skin reactions from a higher energy setting when experiencing greater odor and sweat reduction.

A Pilot Study of the Safety and Effectiveness of a Novel Device in Subjects With Axillary Hyperhidrosis

BACKGROUND

One-third of U.S. adults are bothered by excessive sweating and 5% suffer from hyperhidrosis, both of which negatively affect quality-of-life (QoL). A single-use disposable patch using the novel targeted alkali thermolysis (TAT) technology is being developed to address this condition.

OBJECTIVE

Assess the efficacy and safety of the TAT patch for the treatment of excessive sweating using a randomized, double-blind, sham-controlled study design.

MATERIALS AND METHODS

Adults with Hyperhidrosis Disease Severity Scale (HDSS) scores of 3 or 4 ( n = 16) were treated with an active or sham patch for up to 3 minutes (as established in a previous unpublished feasibility study) and evaluated weekly for 6 weeks post-treatment. The primary effectiveness measure was improved HDSS at Week-4.

RESULTS

The study met its objective. For the primary efficacy measure, 83% of TAT-treated subjects reported HDSS scores of 1 or 2 at Week-4 versus 0% of sham-treated subjects ( p = .0032). Furthermore, 67% of TAT-treated subjects had a 2-point improvement in HDSS scores versus 0% of sham-treated subjects ( p = .0123). Quality-of-life improvement correlated with HDSS. The TAT patch seemed to be well-tolerated; one transient moderate adverse event that resolved without sequelae was reported.

CONCLUSION

The TAT patch successfully demonstrated efficacy and was well-tolerated.

Treatment of Hyperhidrosis: An Update

Hyperhidrosis is a dermatosis presenting as pathologically excessive focal or generalized sweating. The stigmatizing nature of hyperhidrosis may cause patients to feel embarrassment and apprehension about their symptoms and experience a significant decrease in well-being. Severe cases of hyperhidrosis can also increase the risk of developing psychiatric and somatic comorbidities. Conventional non-surgical treatments of hyperhidrosis include aluminum salts, iontophoresis, botulinum toxin injections, and oral glycopyrronium. In recent years, new topical anticholinergic medications and devices have emerged that may improve the patients' symptoms and even prevent the development of comorbidities. The treatment of hyperhidrosis can be a complex matter and may require the combination of several therapies. The purpose of this paper was to firstly review the literature on existing non-surgical treatment options for hyperhidrosis, and secondly provide a stepwise approach to investigating and treating patients with hyperhidrosis.

Potential use of microwave technology in dermatology

BACKGROUND

Microwaves are used in medicine for diagnostics, and treatment of cancer. Recently, novel microwave devices (Swift^®, Emblation Ltd, UK and miraDry^®, Miramar Labs Inc., CA) have been cleared by the FDA and Health Canada for various dermatological conditions.

OBJECTIVE AND METHODS

To review the dermatological use of microwave-based treatments (plantar warts, corns, actinic keratosis, dermatophytosis, axillary hyperhidrosis, osmidrosis, and hidradenitis suppurativa). Clinical trials, case reports, or in vitro studies for each condition are summarized.

RESULTS AND CONCLUSION

Microwaves are a promising alternative therapy for cutaneous warts, actinic keratosis, axillary hyperhidrosis, and osmidrosis, with favorable safety profiles. However, patients with hidradenitis suppurativa have had negative clinical outcomes. Limited treatment of corns showed good pain reduction but did not resolve hyperkeratosis. A preliminary in vitro study indicated that microwave treatment inhibits the growth of T. rubrum. We present the first case of toenail onychomycosis successfully treated with microwaves. Despite the advancements in the use of microwaves, the mechanism of action in non-ablative treatment is not well understood; further research is needed. More high-quality randomized clinical trials with larger groups and long follow-up periods are also required to evaluate the clinical benefits and possible adverse effects of microwaves in treating dermatological conditions.

Fatal consequence after MiraDry® treatment: Necrotizing fasciitis complicated with streptococcal toxic shock syndrome

MiraDry® is a microwave-based cosmetic device commonly used to treat hyperhidrosis and osmidrosis by affecting apocrine and eccrine sweat glands. In most countries, its application is limited to the axillary region. A healthy woman received MiraDry® treatment in the perineal, genital, and perianal regions for body odor in a cosmetic clinic. She experienced severe adverse effects after treatment, including persistent fever, sustained pain, and bleeding in the treated area. The condition deteriorated rapidly with systemic symptoms, and she died on the sixth day. Group A Streptococcus was detected in her skin in the treated areas, and in blood obtained in the hospital and during autopsy. Combined with the clinical diagnosis and autopsy findings, the woman's death was attributed to fatal necrotizing fasciitis (Fournier's gangrene) complicated by streptococcal toxic shock syndrome. Pathogen inoculation was most likely attributable to skin disruption caused by MiraDry® treatment. The MiraDry® application on the genital and perineum is occasionally performed by cosmetic surgeons; however, this case demonstrates the possibility of a rare but fatal complication. Therefore, this case report may be noteworthy and beneficial in forensic practice, and relevant in cosmetic clinical practice.

Subcutaneous tissue necrosis with fat liquefaction, hematoma, inflammatory mass after microwave-based treatment for axillary hyperhidrosis

Axillary hyperhidrosis (AH) and bromhidrosis are common complaint in Asians for consultation in dermatology.A microwave-based device has gradually become a first-choice option during this decade because of the safety and efficacy both for axillary hyperhidrosis and osmidrosis. Other complications reported are transient median and ulnar neuropathy, brachial plexus injury with sensory and motor dysfunction. We herein report a rare case of subcutaneous tissue necrosis with fat liquefaction, hematoma that occurred after microwave-based treatment. It took three weeks for both sides to recover completely. The case prompt us that one pass treatment for the same treatment area and cooling to relieve the pain for 24 hours. Appropriate restriction of movement should be emphasized within one month after treatment. Moreover, more caution is needed when bumps enlarged rapidly .

Comparison of Long-Term Effectiveness and Safety of Microwave and Surgery in the Treatment of Axillary Osmidrosis: A Single-Center Retrospective Study

BACKGROUND

A microwave-based device is a newly developed method for treating axillary osmidrosis. Few studies have compared the difference between microwave therapy and subcutaneous curettage for axillary osmidrosis.

OBJECTIVE

To compare the long-term effectiveness, complications, and recurrence of osmidrosis after microwave therapy and subcutaneous curettage.

METHODS AND MATERIALS

Medical records of 155 patients with osmidrosis treated with microwave therapy or subcutaneous curettage were reviewed retrospectively. Demographic data, visual analog scale for odor, hyperhidrosis disease scale, complications, and recurrence were analyzed.

RESULTS

Osmidrosis improved significantly in both treatment groups at 6 months. Effective improvement was observed in 90% and 23% of the patients in the surgery and microwave groups, respectively, after 3 years postoperatively. The recurrence rates were 39% and 21% in the microwave and surgery groups, respectively. The transient complication rate was higher in the microwave group, and long-term complications only occurred in the surgery group.

CONCLUSION

Subcutaneous curettage is a more effective approach for axillary osmidrosis. However, microwave therapy is recommended for patients with cosmetic concerns.

Conservative Management of Median Nerve Brachial Plexopathy after Microwave-based MiraDry Treatment for Axillary Hyperhidrosis

Axillary hyperhidrosis is characterized by excessive sweating of the armpits, which can significantly affect quality of life. A new microwave-based therapy, MiraDry (Miramar labs, Sunnyvale, Calif.), is a promising minimally-invasive treatment option. We report a case of unilateral brachial plexus thermal injury in a thin 19-year-old man treated for axillary hyperhidrosis with the MiraDry system. He initially experienced swelling and pain in the left hand and was prescribed 1 week of methylprednisolone. He then presented 1 week later with induration and swelling of bilateral axillae with swelling of left thumb, left index, and left long fingers, decreased sensation in median nerve distribution of the left hand, and the inability to flex the left index finger DIP joint. EMG showed absent median nerve motor and sensory function, consistent with median nerve plexopathy. He was conservatively managed with close observation and regular occupational hand therapy appointments. At his 12-month follow-up, there was complete return of left pronator teres strength, thumb flexion, and index finger flexion. Decreased sensation remained at the tip of the left index finger. We report the case of median nerve palsy after MiraDry therapy for axillary hyperhidrosis in a thin young man. We recommend using low-energy settings and pre-procedural ultrasound for young, thin patients because of the more superficial course of the brachial plexus within the axilla.

Treatment of Axillary hyperhidrosis

BACKGROUND

Axillary hyperhidrosis characterized by excessive sweating in the axillary regions is a frustrating chronic autonomic disorder leading to social embarrassment, impaired quality of life and usually associated with palmoplantar hyperhidrosis. Identifying the condition and its cause is central to the management.

AIM

The aim of this article is to discuss treatment options for axillary hyperhidrosis.

METHODS

Comprehensive literature search using PubMed and Google Scholar was performed to review relevant published articles related to diagnosis and treatment of axillary hyperhidrosis.

RESULTS

Treatment modalities for axillary hyperhydrosis vary from topical and systemic agents to injectables, newer devices and surgical measures. None except for physical measures using devices or surgery, which destroys the sweat glands to remove them, is possibly permanent and most are associated with attendant side effects.

CONCLUSION

Several treatments including medical and surgical option are available for the treatment of axillary hyperhydrosis. Patient education is important component of its management. Individualized approach of management is necessary for optimal outcome of treatment.

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.

Primary hyperhidrosis in children: A review of therapeutics

Primary hyperhidrosis, an idiopathic disease that commonly affects the palms, soles, axillae, or craniofacial region, is characterized by perspiration in excess of what is required for physiologic cooling. This disease begins in childhood or adolescence and negatively impacts emotional, physical, and psychologic well-being. This review explores current therapeutic options for primary hyperhidrosis in the pediatric population, including topical therapies, oral therapies, non-surgical and procedural interventions, and adjunctive therapies. In addition, this review identifies new and emerging treatments and highlights the need for further research and therapeutic options for this impactful disease.

How to diagnose and measure primary hyperhidrosis: a systematic review of the literature

PURPOSE

Hyperhidrosis (i.e. excessive sweating) is diagnosed from patient medical history and physical examination. In addition, focal sweat measurements can substantiate the hyperhidrosis diagnosis. Likewise, the impact of living with hyperhidrosis can be assessed with patient-reported outcome measures. However, no consensus exists on how to diagnose hyperhidrosis, how to quantify the disease, or how to measure the impact hyperhidrosis has on patients. Therefore, the objective of this review was to summarize the literature on diagnostic criteria, focal sweat measurement methods, and patient-reported outcome measures of hyperhidrosis.

METHODS

A literature search of Cochrane Library, Embase, and PubMed was conducted. Studies that included and aimed at developing or validating hyperhidrosis diagnostic criteria, focal sweat measurement methods, or patient-reported outcome measures for individuals with hyperhidrosis were eligible for inclusion. The methodological quality of diagnostic accuracy studies about focal sweat measurement methods was determined using the Quality Assessment of Diagnostic Accuracy Studies-2.

RESULTS

Overall, 33 studies were included. We identified two sets of hyperhidrosis diagnostic criteria, one scale for assessment of severity of hyperhidrosis sweating, four focal sweat measurement methods, and 15 patient-reported outcome measures.

CONCLUSION

The algorithm for diagnosing hyperhidrosis and focal sweat measurement methods needs validation in large cohorts. Most patient-reported outcome measures for hyperhidrosis are not adequately validated. A potential solution is to develop a core outcome set that can standardize outcomes reported in clinical trials.

A case series evaluating microwave-based therapy for axillary hyperhidrosis and bromhidrosis

INTRODUCTION

Axillary hyperhidrosis and bromhidrosis have serious social, emotional, and professional consequences. There are several treatments of axillary hyperhidrosis. We present a case series evaluating the efficacy and safety of microwave device for axillary hyperhidrosis and bromhidrosis.

MATERIALS AND METHODS

Seven patients were included in our case series. Four patients had both hyperhidrosis and bromhidrosis. Three patients had only hyperhidrosis. To evaluate the degree of hyperhidrosis and degree bromhidrosis a self-reported Hyperhidrosis Disease Severity Scale (HDSS) score and 4-point malodor grade were assessed. All patients underwent 1 or 2 microwave treatments. Patients underwent a survey on treatment outcomes and adverse effect conducted through telephone 12 months after their last procedure.

RESULTS

Six of seven patients had a 2-point drop in HDSS score. The four patients with bromhidrosis had a 2-point drop on the self-reported malodor measurement 12 months post treatment. Minor adverse effects related to the therapy occurred.

CONCLUSION

This novel microwave-based treatment was effective for the treatment of axillary hyperhidrosis and bromhidrosis. Patient satisfaction with the procedure is high, and adverse events are typically transient and well tolerated.

Cost-effectiveness of topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis

AIMS

Primary axillary hyperhidrosis (PAHH) is a condition characterized by excessive sweating that negatively impacts health-related quality of life, with significant psychological and social impacts. Glycopyrronium tosylate (GT) is a topical anticholinergic approved in the United States for treatment of PAHH in patients 9 years of age and older. Our objective was to assess the cost-effectiveness of GT as first-line topical therapy compared to topical aluminum chloride from a United States commercial perspective.

MATERIALS AND METHODS

A Markov model was developed consisting of four health states based on the Hyperhidrosis Disease Severity Scale (HDSS) over a time horizon of 5 years with discount rates of 3% for both costs and outcomes. Transitions between health states were driven by HDSS response, defined as an improvement of ≥2 points. Non-responders and those who discontinue could switch to later line treatments or no treatment. Health utility scores were based on HDSS scores, supported by published literature.

RESULTS

Over 5 years, GT yielded 0.12 greater QALYs and 0.93 greater LYs with response compared to treatment with prescription aluminum chloride at an incremental cost of $10,584. Relative to prescription aluminum chloride, GT resulted in an incremental cost-effectiveness ratio (ICER) of $87,238 per QALY gained, $11,349 per LY with response. The ICER fell below $100,000 for 66% of probabilistic sensitivity analysis simulations and below $150,000 for 82% of simulations.

LIMITATIONS

This analysis represents a simplified scenario of a hypothetical PAHH patient. Due to sparse data, assumptions were required for treatment patterns, efficacy, and persistence.

CONCLUSION

Based on the analysis of incremental cost per QALY gained, GT may be cost-effective relative to prescription aluminum chloride at commonly accepted willingness to pay thresholds.

Laser and Light-Based Treatment Modalities for the Management of Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory skin disease characterized by inflammatory nodules, abscesses, and sinus tracts in intertriginous areas that has a significant impact on patient quality of life. Treatments range from topical, intralesional, systemic, and surgical. Furthermore, laser and light-based treatment options have become increasingly popular because of the limitations of adverse effects associated with systemic therapy and decreased down-time associated with laser and light therapy. These modalities are thought to work through a variety of mechanisms including decreasing inflammation, destroying hair follicles, targeting sebaceous glands, killing bacteria, and debulking lesions through ablation. This review explores these laser and light-based treatment modalities for the treatment of hidradenitis suppurativa.

Microwave Thermolysis Reduces Generalized and Social Anxiety in Young Adults With Axillary Hyperhidrosis

BACKGROUND AND OBJECTIVE

Hyperhidrosis (HH) is associated with impairments in quality of life (QOL) and elevated anxiety. Microwave thermolysis is a newer treatment that reduces sweating, yet effects on QOL and emotional symptoms have not been examined. Two treatment sessions are recommended to achieve 80% amelioration of clinical HH. We hypothesized that microwave thermolysis would reduce sweat severity, improve QOL, and reduce anxiety in young adults suffering from axillary HH in a prospective clinical trial.

STUDY DESIGN/MATERIALS AND METHODS

We enrolled 24 young adults (mean age = 23.57 years, 54% female) with elevated scores on the Hyperhidrosis Disease Severity Scale. All participants received one session of microwave thermolysis, and 83% received two sessions. Participants completed measures of sweat severity, QOL, generalized anxiety, social anxiety, social avoidance, and anxious/depressive mood symptoms at baseline; post-first treatment; and following second treatment.

RESULTS

At baseline, all participants had severe sweating; 87.5% had impaired QOL, 75% had elevated social anxiety, 50% with generalized anxiety, 48% with social avoidance, and 38% with anxious/depressed mood. Paired samples t tests indicated significant improvements from baseline to first procedure, including decreased sweating (t(21) = 5.68, P < 0.001), improved QOL (t(23) = 4.97, P < 0.001), and decreased generalized anxiety (t(23) = 8.11, P < 0.001), social anxiety (t(22) = 4.55, P < 0.001), mood symptoms (t(21) = 3.81, P = 0.001), and social avoidance (t(22) = 3.12, P = 0.005). After second treatment, further improvements were noted in sweating (t(18) = 3.28, P = 0.004) and QOL (t(18) = 3.83, P = 0.003), and a marginal trend for generalized anxiety (t(19) = 1.96, P = 0.064).

CONCLUSION

There were significant improvements in sweat severity, skin-specific QOL, generalized anxiety, social anxiety, anxious/depressive symptoms, and social avoidance. The majority of the psychosocial benefit appears to emerge after one treatment of microwave thermolysis, whereas the level of sweat severity and QOL continued to show further improvements after a second treatment. Results would suggest that although two microwave thermolysis sessions are needed for maximal treatment optimization of axillary HH, patients may experience significant benefits in improving psychosocial functioning after just one session. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Update of the S1 guidelines on the definition and treatment of primary hyperhidrosis

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.

Modified Suction-Assisted Cartilage Shaver for Axillary Osmidrosis

Apocrine osmidrosis (AO) is a chronic, recurrent, and disturbing disease characterized by malodorous secretion from apocrine glands. Despite various conservative and nonsurgical treatments, surgical removal of apocrine glands remains the cornerstone for AO treatment. Conventional suction-assisted cartilage shaver is effective; however, there are several risks and complications. Hence, we modified the conventional method to achieve better effectiveness and reduce complications. This paper aims to evaluate the clinical effectiveness and the complications arising from the modified suction-assisted cartilage shaver for AO. Thirty-nine patients (M/F=11/28, average age 26.3 years) received this surgical treatment for AO from 2013 to 2017 in the Department of Dermatology at Kaohsiung Chang Gung Memorial Hospital, Taiwan. A suction-assisted cartilage shaver was introduced for the ultimate removal of the subcutaneous tissue containing the apocrine glands. A 0.5 cm incision was made in the center of the identified elliptical surgical area at each axilla. After defatting, the incision was closed primarily. The defatting skin was anchored to the axillary fascia by using 4-0 sutures without drains. We then evaluated the clinical efficacy and complications. The mean duration of follow-up was 31.8 months (12–68 months). Among patients receiving the modified cartilage shaving for AO, 92.3% achieved excellent-to-good results, 5.1% had acceptable results, and 2.6% had fair results. None of them experienced poor clinical efficacy. There was no skin necrosis, hematoma, nor wound infection after the surgery. There were no recurrences in all these patients 2 years after the surgery. This modified suction-assisted cartilage shaver for AO results in good efficacy, a low complication rate, and a low recurrence rate. The method is superior to the conventional one due to tissue glue-free procedure, greater comfort in postoperative care, minimal wounds, less hematoma, and less skin necrosis. The clinical study registration number of this study is NCT03793374.

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.

The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options

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.

Bilateral brachial plexus injury after MiraDry® procedure for axillary hyperhidrosis: a case report

Multiple treatments are available for primary axillary hyperhidrosis, including non-invasive, microwave based thermal treatments designed to destroy sweat glands in the axilla. Often these procedures involve local anesthetic injection to the axilla, followed by placement of the microwave emitter onto the skin and applying the heat treatment to varying depths of the subcutaneous tissues. CASE REPORT: A 49-year old, thin and active woman (BMI 19.6) underwent microwave based treatment to the bilateral axillary regions. She experienced an electric sensation into the ulnar digits of the right hand during anesthetic injection, and then underwent the microwave thermal treatment. She suffered a bilateral brachial plexus injury with imaging evidence of severe, subcutaneous edema surrounding the nerves of the plexus in the axilla, as well as denervation atrophy of the arm and forearm muscles bilaterally. At the time of evaluation and EMG, 8 months after treatment, she had recovered significant strength in the left upper extremity, but continued to have evidence of a severe radial nerve injury on the right. EMG demonstrated some recovery and observation was recommended followed by secondary reconstruction if required. It is likely that the patient sustained thermal injury to the nerves in the axilla bilaterally, given the close proximity to the skin surface in a patient with a low BMI. CONCLUSION: In thin patients undergoing treatment of primary axillary hyperhidrosis, consideration should be given to the distal brachial plexus which may be at risk of damage with high powered microwave-based therapy.

Interventional management of hyperhidrosis in secondary care: a systematic review

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.

Lasers and Energy-Based Devices in Men

BACKGROUND

The demand for cosmetic treatments with lasers and energy-based devices has increased among men, but there is a dearth of literature that addresses the approach and treatment of cosmetic male patients.

OBJECTIVE

To summarize common cosmetic concerns for which male patients seek cosmetic treatments and to provide sex-specific recommendations for the lasers and energy-based devices that can be used for treatment.

MATERIALS AND METHODS

The authors conducted a literature search using the PubMed/MEDLINE and Google Scholar databases using the search terms male, men, gender, and cosmetic dermatology.

RESULTS

The authors review sex-specific treatment recommendations regarding the use of lasers and energy-based devices for the conditions for which men most commonly seek cosmetic treatment, which include photo-/actinic damage, acne scarring, rhinophyma, hair removal, axillary hyperhidrosis, and loose neck/submental skin. Cosmetic issues the authors will touch on, but whose approaches or considerations vary less in men compared with women, are hyperpigmentation, vascular lesions, and facial rejuvenation.

CONCLUSION

Sex-specific treatment approaches with lasers and energy-based devices should be used to best serve male cosmetic patients.

Current and Emerging Medical Therapies for Primary Hyperhidrosis

Hyperhidrosis is defined as the production of sweat beyond what is physiologically necessary to maintain thermal homeostasis. This disease state may (and typically does) have a significant impact on the patient’s quality of life. Medications including antiperspirants, anticholinergics, and botulinum toxin have been shown to be effective in the management of hyperhidrosis. Several medical device technologies have also proven to be effective. This review article will explore the current and emerging pharmacological and medical device treatments for hyperhidrosis and provide a framework for treating patients who suffer with primary forms of hyperhidrosis.

Treatment of Primary Axillary Hyperhidrosis by Fractional Microneedle Radiofrequency: Is it Still Effective after Long-term Follow-up?

Background:

Primary axillary hyperhidrosis (PAH) is a chronic idiopathic disorder causing major stress in patients. Among the common therapies for PAH, only surgical interventions have proven feasible as a permanent solution.

Objective and Aim:

The aim of this study was to evaluate the efficacy and safety of fractional microneedle radiofrequency (FMR) as an alternative permanent treatment for PAH with long-term follow-up.

Materials and Methods:

This was a single-blind, sham-controlled comparative study. Twenty-five patients with severe PAH were provided three treatments of FMR at 3-week intervals (the treatment group), and a control group was provided the sham treatment. Clinical efficacy was evaluated using the hyperhidrosis disease severity scale (HDSS) at baseline and the end of the study, as well as during the 1 year follow-up phase.

Results:

HDSS demonstrated significant improvement after treatment in the treatment group compared to the sham control. The mean (±standard deviation) of HDSS in the group being treated with radiofrequency was 2.50 (±0.88) after 1 year follow-up, and that of the control group was 3.38 (±0.49; P < 0.001). Follow-up results show that there were 10 patients (41.6%) with no relapse and 11 patients (45.9%) with relapse after 1 year. There was a significant correlation between HDSS changes in relapse and body mass index (BMI) (P = 0.03).

Conclusion:

Treatment of PAH with FMR is a safe and noninvasive procedure with a positive therapeutic effect on HDSS. It is recommended, however, that sessions of FMR be repeated after 1 year, particularly in overweight patients with high BMIs.

Clinical Trial Registration:

IRCT2013111915455N1.

Level of Evidences:

Level II-1.