FPIN's Clinical Inquiries

Treatment of Hyperhidrosis



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Am Fam Physician. 2011 Feb 15;83(4):464-466.

Clinical Question

What treatments are effective for excessive sweating (i.e., hyperhidrosis)?

Evidence-Based Answer

OnabotulinumtoxinA injections (Botox; formerly botulinum toxin type A) are effective for the treatment of primary axillary and palmar hyperhidrosis. (Strength of Recommendation [SOR]: A, based on a systematic review of randomized controlled trials). Topical aluminum chloride (Drysol) is effective for the treatment of palmar hyperhidrosis. (SOR: B, based on one small controlled study). Iontophoresis is effective for treating palmar, plantar, and axillary hyperhidrosis. (SOR: C, based on one unblinded, randomized controlled trial). There are no identified randomized, placebo-controlled trials of thoracoscopic sympathectomy or systemic medical therapy for the treatment of hyperhidrosis.

Evidence Summary

Hyperhidrosis is a common disorder, affecting an estimated 2.8 percent of the U.S. population.1 Focal hyperhidrosis most commonly affects the axillae, palms, and soles. OnabotulinumtoxinA injections, topical aluminum chloride, and iontophoresis have been investigated for treating focal and multifocal hyperhidrosis. There have been only case series of thoracoscopic sympathectomy or systemic medical therapy for the treatment of hyperhidrosis.

A systematic review assessing the effectiveness of onabotulinumtoxinA injection for a variety of conditions, including hyperhidrosis, concluded that it is effective for the treatment of axillary hyperhidrosis and likely effective for palmar hyperhidrosis.2  Five randomized controlled trials consistently found that onabotulinumtoxinA injections reduced sweat production or symptoms (Table 1).37 OnabotulinumtoxinA injections have been shown to be effective for at least 16 weeks.4

Table 1.

Randomized Controlled Trials of OnabotulinumtoxinA (Botox) Injections for the Treatment of Hyperhidrosis

Area treated No. of patients Follow-up period Outcome measured Results

Axillae3

322

4 weeks

> 50 percent reduction in symptoms, based on HDSS Improvement in quality of life

NNT = 2*; P < .001 NNT = 5*; P < .001

Axillae4

320

16 weeks

≥ 50 percent reduction in sweat production from baseline

NNT = 2*; P < .001

Axillae5

40

8 weeks

> 50 percent reduction in symptoms, based on HDSS

NNT = 2*; P < .001

Palm6

19

28 days

Gravimetric measurement and subjective rating as successful

NNT = 1*; P < .001

Palm7

11

13 weeks

Reduction in sweat production

Mean sweat reduction at 13 weeks = 0.31 (P < .001; 95% confidence interval, 0.20 to 0.42)†


HDSS = Hyperhidrosis Disease Severity Scale; NNT = number needed to treat.

*—Confidence intervals were not reported.

†—Continuous data; risk reductions and NNT not calculated.

Information from references 3 through 7.

Table 1.   Randomized Controlled Trials of OnabotulinumtoxinA (Botox) Injections for the Treatment of Hyperhidrosis

View Table

Table 1.

Randomized Controlled Trials of OnabotulinumtoxinA (Botox) Injections for the Treatment of Hyperhidrosis

Area treated No. of patients Follow-up period Outcome measured Results

Axillae3

322

4 weeks

> 50 percent reduction in symptoms, based on HDSS Improvement in quality of life

NNT = 2*; P < .001 NNT = 5*; P < .001

Axillae4

320

16 weeks

≥ 50 percent reduction in sweat production from baseline

NNT = 2*; P < .001

Axillae5

40

8 weeks

> 50 percent reduction in symptoms, based on HDSS

NNT = 2*; P < .001

Palm6

19

28 days

Gravimetric measurement and subjective rating as successful

NNT = 1*; P < .001

Palm7

11

13 weeks

Reduction in sweat production

Mean sweat reduction at 13 weeks = 0.31 (P < .001; 95% confidence interval, 0.20 to 0.42)†


HDSS = Hyperhidrosis Disease Severity Scale; NNT = number needed to treat.

*—Confidence intervals were not reported.

†—Continuous data; risk reductions and NNT not calculated.

Information from references 3 through 7.

Aluminum chloride may be effective for treating hyperhidrosis. In a single-blind trial of 12 Chinese men diagnosed with palmar hyperhidrosis, participants used topical aluminum chloride nightly on one palm for four weeks.8 Each participant used his opposite palm as the control. Sweat vapor loss was measured with an evaporimeter. All participants had a statistically significant reduction in sweat vapor after four weeks, but returned to baseline after treatment was stopped.

Iontophoresis may be effective for treating hyperhidrosis. In a controlled study of 22 patients with focal hyperhidrosis (including the axillae, palms, and soles), one-half of participants' affected areas were treated with tap water iontophoresis.9 Patients served as their own controls, and were treated until symptoms resolved. The longest duration of treatment was 41 days. Patients were reevaluated at the final treatment and at one month after the final treatment. Sweat output was measured using Persprint paper and computer analysis. Overall, 93 percent of the affected areas had responded to treatment by day 20.

A single-blind, right-left comparison study of 20 patients with palmoplantar hyperhidrosis compared tap water iontophoresis with glycopyrrolate iontophoresis. In patients treated with glycopyrrolate iontophoresis, the median number of days of self-reported hand dryness was 11, compared with three days for those treated with tap water iontophoresis (P < .0001).10

Recommendations from Others

The Canadian Hyperhidrosis Advisory Committee recommends topical aluminum chloride in a concentration of 20 to 50 percent for treating mild focal or multifocal hyperhidrosis.11 For patients with moderate to severe hyperhidrosis, the committee recommends starting treatment with topical aluminum chloride, and, if ineffective, trying iontophoresis or onabotulinumtoxinA injections. Further interventions, such as surgery, should be reserved for patients who do not respond to less invasive interventions.

Address correspondence to John Woodrow Saenz, MD, at John.Saenz@med.navy.mil. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Navy Medical Department or the U.S. Navy at large.


Copyright Family Physicians Inquiries Network. Used with permission.

REFERENCES

1. Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. 2004;51(2):241–248.

2. Naumann M, So Y, Argoff CE, et al. Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2008;70(19):1707–1714.

3. Lowe NJ, Glaser DA, Eadie N, Daggett S, Kowalski JW, Lai PY; North American Botox in Primary Axillary Hyperhidrosis Clinical Study Group. Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. J Am Acad Dermatol. 2007;56(4):604–611.

4. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ. 2001;323(7313):596–599.

5. Connor KM, Cook JL, Davidson JR. Botulinum toxin treatment of social anxiety disorder with hyperhidrosis: a placebo-controlled double-blind trial. J Clin Psychiatry. 2006;67(1):30–36.

6. Lowe NJ, Yamauchi PS, Lask GP, Patnaik R, Iyer S. Efficacy and safety of botulinum toxin type A in the treatment of palmar hyperhidrosis: a double-blind, randomized, placebo-controlled study. Dermatol Surg. 2002;28(9):822–827.

7. Schnider P, Binder M, Auff E, Kittler H, Berger T, Wolff K. Double-blind trial of botulinum A toxin for the treatment of focal hyperhidrosis of the palms. Br J Dermatol. 1997;136(4):548–552.

8. Goh CL. Aluminum chloride hexahydrate versus palmar hyperhidrosis. Evaporimeter assessment. Int J Dermatol. 1990;29(5):368–370.

9. Akins DL, Meisenheimer JL, Dobson RL. Efficacy of the Drionic unit in the treatment of hyperhidrosis. J Am Acad Dermatol. 1987;16(4):828–832.

10. Dolianitis C, Scarff CE, Kelly J, Sinclair R. Iontophoresis with glycopyrrolate for the treatment of palmoplantar hyperhidrosis. Australas J Dermatol. 2004;45(4):208–212.

11. Solish N, Bertucci V, Dansereau A, et al. A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007;33(8):908–923.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.



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