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Treatment of hyperhidrosis
This month’s selected commentary
Treatment of hyperhidrosis Warren R. Heymann, MD Based on a dialogue between Drs Ramsey Markus and John Wolf Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editor-inChief, Warren R. Heymann, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology. ( J Am Acad Dermatol 2005;52:509-10.)
A
lthough sweat is the ‘‘cologne of accomplishment’’ according to Heywood Hale Broun, there is little doubt that primary hyperhidrosis may adversely affect one’s quality of life. There are several therapeutic interventions that may ameliorate this condition, ranging from topical antiperspirants, anticholinergics, iontophoresis, injection of botulinum toxin, transthoracic sympathectomy, excision or liposuction removal of the axillary glands, or psychotherapy.1 This commentary will focus on the use of botulinum toxin for axillary hyperhidrosis. Patients with hyperhidrosis experience substantial functional and emotional problems. In a study of 41 patients treated with botulinum toxin A, all experienced improvement in their quality of life, based on their score of the Dermatology Life Quality Index (DQLI) questionnaire, which was administered before and two weeks after treatment with botulinum toxin.2 Most studies for botulinum toxin in the treatment of hyperhidrosis have utilized the type A toxin. Heckmann et al3 conducted a multicenter trial of botulinum toxin A in 145 patients with axillary hyperhidrosis. In each patient, 200 units were injected into one axilla, and placebo was injected into the other in a randomized, double-blind manner. Two weeks later, after the treatments were revealed, the axilla that had received placebo was injected with 100 units of botulinum toxin A. Changes in the rates of sweat production were measured by gravimetry. At baseline, the rate of sweat production was 192 6 136 mg per minute. Two weeks after the first injections, the mean rate of sweat production in the axilla that received botulinum toxin A was 24 6 27 mg per minute, as compared to 144 6 113 mg per
The statements and opinions expressed in this commentary are those of the Editor-in-Chief of Dialogues in Dermatology.
minute in the axilla that received placebo. This difference is statistically significant. The injection of 100 units into the axilla that had been treated with placebo reduced the mean rate of sweat production in that axilla to 32 6 39 mg per minute, also statistically significant. Twenty-four weeks after the injection of 100 units, the rates of sweat production (in the 136 patients in whom the rates were measured at that time) were still lower than baseline values, at 67 6 66 mg per minute in the axilla that received 200 units and 65 6 64 mg per minute in the axilla that received placebo and 100 units of the toxin. Treatment was well tolerated: 98% of the patients said they would recommend this therapy to others.3 Naumann and Lowe4 studied 307 patients who completed a trial and received either 50 units per axilla or placebo. They considered ‘‘responders’’ those who had greater than a 50% reduction from baseline of spontaneous axillary sweat production at 4 weeks. At 4 weeks, 94% of the treated group had responded, compared to 36% of the placebo group. By week 16, response rates were 82% and 21%, respectively.4 Patients require repeated injections of botulinum toxin A to keep hyperhidrosis in remission. Lowe et al5 studied 12 patients in an 18-month open-label, noncomparative trial. Patients received up to four treatments of intradermal botulinum toxin A (2 ml, 50 units). They found that in this timeframe, five patients (42%) required a total of two active injections, three patients (25%) needed three, and four (33%) received four injections. The mean time between the first and second treatment in this study was just over 29 weeks, with a range of 17.8 to 57.5 weeks. The authors concluded that repeated injections of botulinum toxin are an effective treatment for axillary hyperhidrosis.5 509
510 Dialogues in Dermatology
Bromidrosis can be an awkward problem for patients and those in their surroundings. Heckman et al6 studied 16 healthy volunteers who were injected with botulinum toxin A in one axilla and 0.9% sodium chloride in the other axilla in a randomized, double-blind fashion. After 7 days, body odor was assessed by a T-shirt sniff test. A significant reduction of odor intensity was observed for the botulinum toxin Aetreated side. The smell was also rated significantly less unpleasant. The authors suggest that botulinum toxin A can ameliorate or even improve body odor. They surmise that the underlying mechanisms may include interference with skin microbes and denervation of apoeccrine sweat glands.6 Injections of botulinum toxin A may also result in the resolution of axillary granular parakeratosis.7 Surgical approaches, such as excision of the axillary apoeccrine glands, offer a potential for a permanent reduction of hyperhidrosis. Indeed, Field8 posed the question: ‘‘Why would one sentence a patient to a lifetime of medical expense when a single surgical intervention has every reasonable expectation of being curative and is even less uncomfortable and distressing than the multiple needle injection technique of BOTOX administration?’’ He was referring to suction curettage after tumescent anesthetic distention of the axillary vault. Rompel and Scholz9 studied a total of 113 patients, 90 of whom were treated by subcutaneous curettage and 23 with injection of botulinum toxin A. Median follow-up was 23.5 months. The patient satisfaction scores were similar for both groups, with 36.4% of the curettage group reporting their results as ‘‘very good’’ compared with 39.1% of those patients receiving botulinum toxin injection. The authors of this study concluded that both techniques are major advances in the treatment of hyperhidrosis. Subcutaneous curettage offers the same permanent efficacy, but far fewer side effects than sympathectomy, and less scarring than local excisional procedures. Of the conservative approaches, botulinum toxin A is by far the most efficacious. They recommend that patients be informed of the advantages and disadvantages of both methods.9
J AM ACAD DERMATOL MARCH 2005
REFERENCES 1. Connolly M, de Berker D. Management of primary hyperhidrosis: a summary of the different treatment modalities. Am J Clin Dermatol 2003;4:681-97. 2. Campanati A, Penna L, Guzzo T, Menotta L, Silvestri B, Lagalla G, et al. Quality-of-life in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study. Clin Ther 2003;25:298-308. 3. Heckman M, Ceballos-Baumann AO, Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med 2001;344:488-93. 4. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomized, parallel group, double blind, placebo controlled trial. BMJ 2001;323: 596-9. 5. Lowe PL, Cerdan-Sanz S, Lowe NJ. Botulinum toxin type A in the treatment of bilateral primary axillary hyperhidrosis: efficacy and duration with repeated treatments. Dermatol Surg 2003;29: 545-8. 6. Heckman M, Teichman B, Pause B, Plewig G. Amelioration of body odor after intracutaneous axillary injection of botulinum toxin A. Arch Dermatol 2003;139:57-9. 7. Ravitskiy L, Heymann WR. Botulin toxin-induced resolution of axillary granular parakeratosis. Skinmed (in press). 8. Field L. Re: Botox for a lifetime or tumescent axillary liposuction and curettage once. Dermatol Surg 2003;29:793-4. 9. Rompel R, Scholz S. Subcutaneous curettage vs. injection of botulinum toxin A for treatment of axillary hyperhidrosis. J Eur Acad Dermatol Venereol 2001;15:207-11.
Additional topics from the March 2005 issue of the Dialogues in Dermatology: 1. Botanical dermatoses Drs Scott A. Norton and Maurice Thew 2. Psoriatic arthritis Drs Bruce E. Strober and Gary Brauner Dialogues in Dermatology is published monthly by the American Academy of Dermatology in both audio cassette and CD formats. Corporate and editorial offices: 930 E. Woodfield Dr, Schaumburg, IL 60173-4729. 2004 subscription rates: $150 for individuals in the United States, Canada, and Mexico; $200 International. ª 2005 by the American Academy of Dermatology, Inc. Subscriptions are available by calling toll-free: 866-503-7546 or faxing 847-240-1859. Additional information is available in the Marketplace section of www.aad.org.
Treatment of hyperhidrosis Warren R. Heymann, MD Based on a dialogue between Drs Ramsey Markus and John Wolf Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editor-inChief, Warren R. Heymann, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology. ( J Am Acad Dermatol 2005;52:509-10.)
A
lthough sweat is the ‘‘cologne of accomplishment’’ according to Heywood Hale Broun, there is little doubt that primary hyperhidrosis may adversely affect one’s quality of life. There are several therapeutic interventions that may ameliorate this condition, ranging from topical antiperspirants, anticholinergics, iontophoresis, injection of botulinum toxin, transthoracic sympathectomy, excision or liposuction removal of the axillary glands, or psychotherapy.1 This commentary will focus on the use of botulinum toxin for axillary hyperhidrosis. Patients with hyperhidrosis experience substantial functional and emotional problems. In a study of 41 patients treated with botulinum toxin A, all experienced improvement in their quality of life, based on their score of the Dermatology Life Quality Index (DQLI) questionnaire, which was administered before and two weeks after treatment with botulinum toxin.2 Most studies for botulinum toxin in the treatment of hyperhidrosis have utilized the type A toxin. Heckmann et al3 conducted a multicenter trial of botulinum toxin A in 145 patients with axillary hyperhidrosis. In each patient, 200 units were injected into one axilla, and placebo was injected into the other in a randomized, double-blind manner. Two weeks later, after the treatments were revealed, the axilla that had received placebo was injected with 100 units of botulinum toxin A. Changes in the rates of sweat production were measured by gravimetry. At baseline, the rate of sweat production was 192 6 136 mg per minute. Two weeks after the first injections, the mean rate of sweat production in the axilla that received botulinum toxin A was 24 6 27 mg per minute, as compared to 144 6 113 mg per
The statements and opinions expressed in this commentary are those of the Editor-in-Chief of Dialogues in Dermatology.
minute in the axilla that received placebo. This difference is statistically significant. The injection of 100 units into the axilla that had been treated with placebo reduced the mean rate of sweat production in that axilla to 32 6 39 mg per minute, also statistically significant. Twenty-four weeks after the injection of 100 units, the rates of sweat production (in the 136 patients in whom the rates were measured at that time) were still lower than baseline values, at 67 6 66 mg per minute in the axilla that received 200 units and 65 6 64 mg per minute in the axilla that received placebo and 100 units of the toxin. Treatment was well tolerated: 98% of the patients said they would recommend this therapy to others.3 Naumann and Lowe4 studied 307 patients who completed a trial and received either 50 units per axilla or placebo. They considered ‘‘responders’’ those who had greater than a 50% reduction from baseline of spontaneous axillary sweat production at 4 weeks. At 4 weeks, 94% of the treated group had responded, compared to 36% of the placebo group. By week 16, response rates were 82% and 21%, respectively.4 Patients require repeated injections of botulinum toxin A to keep hyperhidrosis in remission. Lowe et al5 studied 12 patients in an 18-month open-label, noncomparative trial. Patients received up to four treatments of intradermal botulinum toxin A (2 ml, 50 units). They found that in this timeframe, five patients (42%) required a total of two active injections, three patients (25%) needed three, and four (33%) received four injections. The mean time between the first and second treatment in this study was just over 29 weeks, with a range of 17.8 to 57.5 weeks. The authors concluded that repeated injections of botulinum toxin are an effective treatment for axillary hyperhidrosis.5 509
510 Dialogues in Dermatology
Bromidrosis can be an awkward problem for patients and those in their surroundings. Heckman et al6 studied 16 healthy volunteers who were injected with botulinum toxin A in one axilla and 0.9% sodium chloride in the other axilla in a randomized, double-blind fashion. After 7 days, body odor was assessed by a T-shirt sniff test. A significant reduction of odor intensity was observed for the botulinum toxin Aetreated side. The smell was also rated significantly less unpleasant. The authors suggest that botulinum toxin A can ameliorate or even improve body odor. They surmise that the underlying mechanisms may include interference with skin microbes and denervation of apoeccrine sweat glands.6 Injections of botulinum toxin A may also result in the resolution of axillary granular parakeratosis.7 Surgical approaches, such as excision of the axillary apoeccrine glands, offer a potential for a permanent reduction of hyperhidrosis. Indeed, Field8 posed the question: ‘‘Why would one sentence a patient to a lifetime of medical expense when a single surgical intervention has every reasonable expectation of being curative and is even less uncomfortable and distressing than the multiple needle injection technique of BOTOX administration?’’ He was referring to suction curettage after tumescent anesthetic distention of the axillary vault. Rompel and Scholz9 studied a total of 113 patients, 90 of whom were treated by subcutaneous curettage and 23 with injection of botulinum toxin A. Median follow-up was 23.5 months. The patient satisfaction scores were similar for both groups, with 36.4% of the curettage group reporting their results as ‘‘very good’’ compared with 39.1% of those patients receiving botulinum toxin injection. The authors of this study concluded that both techniques are major advances in the treatment of hyperhidrosis. Subcutaneous curettage offers the same permanent efficacy, but far fewer side effects than sympathectomy, and less scarring than local excisional procedures. Of the conservative approaches, botulinum toxin A is by far the most efficacious. They recommend that patients be informed of the advantages and disadvantages of both methods.9
J AM ACAD DERMATOL MARCH 2005
REFERENCES 1. Connolly M, de Berker D. Management of primary hyperhidrosis: a summary of the different treatment modalities. Am J Clin Dermatol 2003;4:681-97. 2. Campanati A, Penna L, Guzzo T, Menotta L, Silvestri B, Lagalla G, et al. Quality-of-life in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study. Clin Ther 2003;25:298-308. 3. Heckman M, Ceballos-Baumann AO, Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med 2001;344:488-93. 4. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomized, parallel group, double blind, placebo controlled trial. BMJ 2001;323: 596-9. 5. Lowe PL, Cerdan-Sanz S, Lowe NJ. Botulinum toxin type A in the treatment of bilateral primary axillary hyperhidrosis: efficacy and duration with repeated treatments. Dermatol Surg 2003;29: 545-8. 6. Heckman M, Teichman B, Pause B, Plewig G. Amelioration of body odor after intracutaneous axillary injection of botulinum toxin A. Arch Dermatol 2003;139:57-9. 7. Ravitskiy L, Heymann WR. Botulin toxin-induced resolution of axillary granular parakeratosis. Skinmed (in press). 8. Field L. Re: Botox for a lifetime or tumescent axillary liposuction and curettage once. Dermatol Surg 2003;29:793-4. 9. Rompel R, Scholz S. Subcutaneous curettage vs. injection of botulinum toxin A for treatment of axillary hyperhidrosis. J Eur Acad Dermatol Venereol 2001;15:207-11.
Additional topics from the March 2005 issue of the Dialogues in Dermatology: 1. Botanical dermatoses Drs Scott A. Norton and Maurice Thew 2. Psoriatic arthritis Drs Bruce E. Strober and Gary Brauner Dialogues in Dermatology is published monthly by the American Academy of Dermatology in both audio cassette and CD formats. Corporate and editorial offices: 930 E. Woodfield Dr, Schaumburg, IL 60173-4729. 2004 subscription rates: $150 for individuals in the United States, Canada, and Mexico; $200 International. ª 2005 by the American Academy of Dermatology, Inc. Subscriptions are available by calling toll-free: 866-503-7546 or faxing 847-240-1859. Additional information is available in the Marketplace section of www.aad.org.