Effects of a long-pulsed 800-nm diode laser on axillary hyperhidrosis: a randomized controlled half-side comparison study

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.

A systematic evidence-based review of treatments for primary hyperhidrosis

Objective

Hyperhidrosis (excessive sweating) is associated with significant quality-of-life burden yet is often undertreated. With limited FDA-approved treatments, health care providers must determine optimal treatment among approved and off-label options. Key objectives of this review were to reassess, update, and expand a previous systematic review of commonly used treatment options for primary hyperhidrosis, including consideration of aluminum and zirconium compounds.

Methods

We performed a qualitative systematic review of efficacy, health-related quality of life, satisfaction, and safety of interventions, replicating and expanding the strategy outlined in a previous systematic review, with the addition of studies utilizing a within-patient design. We performed a critical appraisal of identified studies to determine risk of bias (RoB) and strength of evidence (SOE).

Results

A total of 32 studies were eligible for critical appraisal. Only three studies - two clinical trials of glycopyrronium cloth (2.4%) and one trial of botulinum toxin A injections in axillary hyperhidrosis were rated as "low" RoB; both had SOE ratings of "moderate" for use in axillary hyperhidrosis - the highest rating included in this review.

Conclusions

Optimal treatment choice depends on several factors, including understanding the quality of evidence regarding each treatment's efficacy and safety (considerations of convenience and cost are beyond the scope of this review). In hyperhidrosis, as in other clinical conditions, treatment decisions should be patient centered. At this time, because of the quality of evidence, only imprecise estimates of effect are possible for hyperhidrosis treatments included in this review, and statements about comparative effectiveness are not possible.

Short-Term Clinical Outcomes and Safety Associated With Percutaneous Radiofrequency Treatment for Excessive Sweating

BACKGROUND

Primary excessive sweating of the axilla affects approximately 3.12% of the US population and has a negative impact on individuals' lives.

OBJECTIVES

We report the safety and effectiveness up to 90 days after treating excessive sweating with percutaneous radiofrequency when using a standardized protocol.

METHODS

Twenty adult subjects (13 females, 7 males) aged 18-49 years with excessive sweating were enrolled in a single-center, single-treatment unblinded prospective study conducted at the FACES+ Aesthetic Facility. Forty axilla were treated using the ThermiGen ThermiRF device. The Dermatology Quality of Life Index (DLQI), the Hyperhidrosis Disease Severity Scale (HDSS), and the Odor Scale (OS) were used for qualitative assessment.

RESULTS

Primary and secondary exploratory evaluations were favorable at 90 days, indicating a significant improvement in quality of life and a significant reduction in both sweating and odor. The DLQI demonstrated an average improvement of 10.8 points at day 30, 10.7 at day 60, and 11.1 at day 90 (P = 0.0001). At day 90, 100% of individuals had ≥50% improvement in their excessive sweating based on the HDSS. At the conclusion of the study, 15 subjects had a ≥1-point drop in their OS, whereas 5 subjects had no change (P = 0.0002). There were no serious adverse events reported during this study. All adverse events were classified as mild and moderate and resolved within 2 months.

CONCLUSIONS

The addition of the ThermiRF temperature-controlled radiofrequency device to the algorithm of hyperhidrosis treatments reduces sweating and odor with minimal downtime.

LEVEL OF EVIDENCE: 4

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.

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.

Split-axilla comparison study of 0.5-MHz, invasive, bipolar radiofrequency treatment using insulated microneedle electrodes for primary axillary hyperhidrosis

BACKGROUND

Energy-delivering devices can be used to induce thermal coagulation of the eccrine sweat glands for treating primary axillary hyperhidrosis (PAH).

OBJECTIVE

The objective of this study was to compare the efficacy and safety of invasive, bipolar radiofrequency (RF) treatment for PAH.

METHODS

A split-axilla study was performed to compare the clinical outcomes of 0.5 MHz, invasive, bipolar RF treatment with treatment settings of a longer conduction time and lower power (LC/LP) vs a shorter conduction time and higher power (SC/HP) for treating PAH.

RESULTS

The in vivo study revealed median hyperhidrosis disease severity scale scores of 1.5 (interquartile range [IQR], 1-2) at 1 month and 1 (IQR, 1-2) at 3 months after treatment with the LC/LP setting, compared to baseline. Meanwhile, the other side of the axillae treated with the SC/HP setting showed scores of 2 (IQR, 2-2) at 1 month and 2 (IQR, 1.25-2) at 3 months. Analysis via a linear mixed model revealed a significant interaction (group, P = .011; time, P < .001; and group × time, P = .048) between treatment group and time.

CONCLUSION

PAH can be effectively and safely treated with invasive, multilayered, multiple-pass, 0.5-MHz, bipolar RF treatment, particularly with LC/LP.

Laser treatment of primary axillary hyperhidrosis: a review of the literature

Hyperhidrosis o`ccurs when the body produces sweat beyond what is essential to maintain thermal homeostasis. The condition tends to occur in areas marked by high-eccrine density such as the axillae, palms, and soles and less commonly in the craniofacial area. The current standard of care is topical aluminum chloride hexahydrate antiperspirant (10-20%), but other treatments such as anticholinergics, clonidine, propranolol, antiadrenergics, injections with attenuated botulinum toxin, microwave technology, and surgery have been therapeutically implicated as well. Yet, many of these treatments have limited efficacy, systemic side effects, and may be linked with significant surgical morbidity, creating need for the development of new and effective therapies for controlling excessive sweating. In this literature review, we examined the use of lasers, particularly the Neodynium:Yttrium-Aluminum-Garnet (Nd:YAG) and diode lasers, in treating hyperhidrosis. Due to its demonstrated effectiveness and limited side effect profile, our review suggests that Nd:YAG laser may be a promising treatment modality for hyperhidrosis. Nevertheless, additional large, randomized controlled trials are necessary to confirm the safety and efficacy of this treatment option.

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.

Distinguishing hyperhidrosis and normal physiological sweat production: new data and review of hyperhidrosis data for 1980-2013

BACKGROUND

Hyperhidrosis is a condition in which the production of sweat is abnormally increased. No objective criteria for the diagnosis of hyperhidrosis exist, mainly because reference intervals for normal physiological sweat production at rest are unknown.

OBJECTIVE

The main objective of this study was to establish reference intervals for normal physiological axillary and palmar sweat production.

METHODS

Gravimetric testing was performed in 75 healthy control subjects. Subsequently, these results were compared with findings in a cohort of patients with hyperhidrosis and with the results derived from a review of data on hyperhidrosis published between 1980 and 2013.

RESULTS

Approximately 90% of the controls had axillary and palmar sweat production rates of below 100 mg/5 min. In all except one of the axillary and palmar hyperhidrosis studies reviewed, average sweat production exceeded 100 mg/5 min.

CONCLUSIONS

A sweat production rate of 100 mg/5 min as measured by gravimetric testing may be a reasonable cut-off value for distinguishing axillary and palmar hyperhidrosis from normal physiological sweat production.

Management of hyperhidrosis

Primary hyperhidrosis (HH), a condition of sweating in excess of thermoregulatory requirements, affects nearly 3% of the US population and carries significant emotional and psychosocial implications. Unlike secondary HH, primary HH is not associated with an identifiable underlying pathology. Our limited understanding of the precise pathophysiologic mechanism for HH makes its treatment particularly frustrating. However, a wide array of interventions for the treatment of HH have been implemented throughout the world. Herein, we discuss the most extensively studied therapeutic options for primary HH, including systemic oxybutynin, botulinum toxin injections, skin excision, liposuction–curettage, and sympathotomy/sympathectomy. We conclude with a discussion of possible future therapies for HH, including the applications of laser, microwave, and ultrasound technologies.

Hyperhidrosis: review of recent advances and new therapeutic options for primary hyperhidrosis

PURPOSE OF REVIEW

Primary focal hyperhidrosis is a common condition that negatively impacts quality of life for many pediatric patients and can be challenging to treat. Standard treatments for hyperhidrosis can be used with success in many patients, and newer therapies and techniques offer options that have demonstrated efficacy and safety. This review highlights standard therapies for primary focal hyperhidrosis as well as the most recent technique advancements and alternative treatment options.

RECENT FINDINGS

The standard approach to treating primary focal hyperhidrosis remains initiation of topical preparations, followed by advancement to systemic medications, local administration of medication and/or surgical procedures. Recent studies focus on enhancing tolerability of topical preparations as well as evaluating the efficacy of neuromodulator injections, oral anticholinergic medications and laser therapy. Microwave technology has also been introduced for the treatment of focal hyperhidrosis with promising results.

SUMMARY

Many therapies exist for hyperhidrosis, and each treatment plan must be evaluated on a patient-by-patient basis. Advances in standard therapies and emergence of new treatment techniques are the main emphases of current published literature on hyperhidrosis. This article presents recent therapeutic options as well as updates on more established strategies to help practitioners treat this challenging condition.