What dermatologic disease has the highest Dermatology Life Quality Index score? Providers may be surprised to find out that it is not atopic dermatitis or psoriasis but actually hyperhidrosis (also known as excessive sweating) that has the greatest impact on patient well-being.
At Winter Clinical Dermatology Conference, David M. Pariser, MD, presented on hyperhidrosis and offered a number of pearls to take to practice. Dr Pariser is a professor of dermatology at Eastern Virginia Medical School and the senior physician of Pariser Dermatology Specialists, both in Norfolk, VA.
Out of ADD, depression, obesity, and skin infections, which has not been associated with hyperhidrosis? Check your answer with our quiz from Hyperhidrosis Awareness Month, created in partnership with the International Hyperhidrosis Awareness Society!
Hyperhidrosis is defined as sweating that is in excess of what is needed to maintain the body’s normal thermal regulation.1 It is a very visible, impactful sweating, which regularly soaks through clothing, may cause difficulty in holding items, and prevent normal, everyday activities. Estimated prevalence of the disease is as high as 4.8%.2 While no one dies of hyperhidrosis, but they will certainly “die of embarrassment” from their disease.
Excessive sweating is divided into two subtypes. The first, primary focal hyperhidrosis (PFH), is idiopathic sweating of the axillae, palms, soles, and/or face for duration of at least 6 months. It should have at least two of the following characteristics:
- Bilateral and symmetric sweating
- Significantly impairs daily functions
- Occurs one or more times per week
- Age of onset less that 25 years
- Family history of excessive sweating
- Cessation during sleep
The other variant of hyperhidrosis is secondary generalized hyperhidrosis (SGH). As the name implies, it is caused by another factor, such as a medical condition or medication. One key difference in diagnosis between PFH and SGH is the cessation of sweating during sleeping; this should help dermatologists pinpoint what to target in treatment.
Hyperhidrosis has a number of treatment options at various levels of invasiveness. Noninvasive treatments include topical antiperspirants, topical anticholinergics, and iontophoresis; minimally invasive options include systemic medications, botulinum toxin injections, and microwave thermolysis; and surgery, the most invasive, can be either removal of the axillary tissue or endoscopic thoracic sympathectomy.
Dr Pariser pointed out that most people are using antiperspirants incorrectly. It is commonplace to put antiperspirant on after bathing; however, antiperspirants are most effective when applied overnight to dry skin. This allows the product to mix with perspiration on the skin surface and into the skin duct, creating a shallow plug to reduce the flow of perspiration. He noted that people who shower in the mornings will certainly not wash the antiperspirant away, and these people can apply a deodorant on top.
A recent advancement in treatment is glycopyrronium cloth, which has shown clinically meaningful improvement in disease severity and reductions in sweat production.3,4 The cloth is recommended as a first-line treatment for axillary hyperhidrosis by the International Hyperhidrosis Society. While the product instructions note to “wipe, toss, wash,” patients may be able to get an additional application out of one cloth. They may also be able to use it less frequently than prescribed with results.
Botulinum toxin is also a great choice for treatment, particularly for dermatology practices. In clinical trials, botulinum toxin was shown to be highly effective with a long duration of effect. Patients noted high levels of satisfaction as well as significantly improved quality of life.5 It is also an effective treatment that can help in palmar,6 plantar, inguinal, and craniofacial areas. Injection is also a perfect procedure to be handled by advanced practice clinicians as overseen by a physician.
In a post-presentation interview on YouTube,7 Dr Pariser shared a few additional pearls from his presentation. He stressed the need for patients to be incredibly careful to wash their hands immediately after applying and disposing of glycopyrronium cloth. Patients should avoid touching the face to prevent irritation and mydriasis.
References
1. Hornberger J, Grimes K, Naumann M, et al; Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004;51(2):274-286. doi: 10.1016/j.jaad.2003.12.029
2. Doolittle J, Walker P, Mills T, Thurston J. Hyperhidrosis: an update on prevalence and severity in the United States. Arch Dermatol Res. 2016;308(10:743-749. doi:10.1007/s00403-016-1697-9
3. Glaser DA, Hebert AA, Nast A, et al. Topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis: Results from the ATMOS-1 and ATMOS-2 phase 3 randomized controlled trials. J Am Acad Dermatol. 2019;80(1):128-138.e2. doi:10.1016/j.jaad.2018.07.002
4. Pariser DM, Hebert AA, Drew JJ, Quiring J, Gopalan R, Glaser DA. Topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis: patient-reported outcomes from the ATMOS-1 and ATMOS-2 phase iii randomized controlled trials. Am J Clin Dermatol. 2019;20(1):135-145. doi:10.1007/s40257-018-0395-0
5. Naumann MK, Hamm H, Lowe NJ; Botox Hyperhidrosis Clinical Study Group. Effect of botulinum toxin type A on quality of life measures in patients with excessive axillary sweating: a randomized controlled trial. Br J Dermatol. 2002;147(6):1218-1226. doi:10.1046/j.1365-2133.2002.05059.x
6. Saadia D, Voustianiouk A, Wang AK, Kaufmann H. Botulinum toxin type A in primary palmar hyperhidrosis: randomized, single-blind, two-dose study. Neurology. 2001;57(11):2095-2099. doi:10.1212/wnl.57.11.2095
7. WC21 – Hyperhidrosis pearls | David M. Pariser, MD. FC TV. January 14, 2021. Accessed January 23, 2021. https://youtu.be/VikhqT6-UO
