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

Jamieson, Barbara

Saenz, John Woodrow

Sams, Richard, II

English

University of Missouri: MOspace

464  American Family Physician www.aafp.org/afp	 Volume 83, Number 4 ◆ February 15, 2011Clinical QuestionWhat	 treatments	 are	 effective	 for	 excessive	sweating	(i.e.,	hyperhidrosis)?Evidence-Based AnswerOnabotulinumtoxinA	injections	(Botox;	for-merly	botulinum	toxin	 type	A)	are	effective	for	 the	 treatment	 of	 primary	 axillary	 and	palmar	 hyperhidrosis.	 (Strength	 of	 Recom-mendation	[SOR]:	A,	based	on	a	 systematic	review	of	randomized	controlled	trials).	Top-ical	 aluminum	 chloride	 (Drysol)	 is	 effective	for	 the	 treatment	 of	 palmar	 hyperhidrosis.	(SOR:	 B,	 based	 on	 one	 small	 controlled	study).	 Iontophoresis	 is	 effective	 for	 treat-ing	 palmar,	 plantar,	 and	 axillary	 hyperhi-drosis.	 (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 SummaryHyperhidrosis	is	a	common	disorder,	affect-ing	 an	 estimated	 2.8	 percent	 of	 the	 U.S.	population.1	Focal	hyperhidrosis	most	com-monly	 affects	 the	 axillae,	 palms,	 and	 soles.	OnabotulinumtoxinA	injections,	topical	alu-minum	 chloride,	 and	 iontophoresis	 have	been	investigated	for	treating	focal	and	mul-tifocal	 hyperhidrosis.	 There	 have	 been	 only	case	 series	 of	 thoracoscopic	 sympathectomy	or	 systemic	 medical	 therapy	 for	 the	 treat-ment	of	hyperhidrosis.	A	 systematic	 review	 assessing	 the	 effec-tiveness	 of	 onabotulinumtoxinA	 injection	for	a	variety	of	conditions,	including	hyper-hidrosis,	 concluded	 that	 it	 is	 effective	 for	the	 treatment	of	axillary	hyperhidrosis	and	likely	 effective	 for	 palmar	 hyperhidrosis.2	Five	 randomized	 controlled	 trials	 consis-tently	 found	 that	 onabotulinumtoxinA	injections	 reduced	 sweat	 production	 or	symptoms	 (Table 1).3-7	 Onabotulinum-toxinA	 injections	 have	 been	 shown	 to	 be	effective	for	at	least	16	weeks.4	Aluminum	 chloride	 may	 be	 effective	 for	treating	hyperhidrosis.	In	a	single-blind	trial	of	 12	 Chinese	 men	 diagnosed	 with	 palmar	hyperhidrosis,	participants	used	topical	alu-minum	 chloride	 nightly	 on	 one	 palm	 for	four	weeks.8	Each	participant	used	his	oppo-site	palm	as	the	control.	Sweat	vapor	loss	was	measured	with	an	evaporimeter.	All	partici-pants	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	treat-ment	by	day	20.A	 single-blind,	 right-left	 comparison	study	 of	 20	 patients	 with	 palmoplantar	hyperhidrosis	 compared	 tap	 water	 ionto-phoresis	 with	 glycopyrrolate	 iontophoresis.	In	patients	 treated	with	glycopyrrolate	 ion-tophoresis,	 the	 median	 number	 of	 days	 of	self-reported	 hand	 dryness	 was	 11,	 com-pared	with	three	days	for	those	treated	with	tap	water	iontophoresis	(P	<	.0001).10Treatment of HyperhidrosisJOHN	WOODROW	SAENZ,	MD,	and	RICHARD	W.	SAMS	II,	MD,	MA Naval Hospital Jacksonville Family Medicine Residency Program, Jacksonville, FloridaBARBARA	JAMIESON,	MLS,	Medical College of Wisconsin, Milwaukee, WisconsinClinical 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 medi-cine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recom-mendations 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 pub-lished in AFP is available at http://www.aafp.org/afp/fpin.FPIN’s Clinical Inquiries▲Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.Clinical Inquiries466  American Family Physician www.aafp.org/afp	 Volume 83, Number 4 ◆ February 15, 2011Recommendations from OthersThe	Canadian	Hyperhidrosis	Advisory	Com-mittee	recommends	topical	aluminum	chlo-ride	 in	 a	 concentration	 of	 20	 to	 50	 percent	for	treating	mild	focal	or	multifocal	hyperhi-drosis.11	For	patients	with	moderate	to	severe	hyperhidrosis,	 the	 committee	 recommends	starting	 treatment	 with	 topical	 aluminum	chloride,	and,	if	ineffective,	trying	iontopho-resis	or	onabotulinumtoxinA	injections.	Fur-ther	interventions,	such	as	surgery,	should	be	reserved	for	patients	who	do	not	respond	to	less	invasive	interventions.Copyright Family Physicians Inquiries Network. Used with permission.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. 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.REFERENCES	 1.	Strutton	 DR,	 Kowalski	 JW,	 Glaser	 DA,	 Stang	 PE.	US	prevalence	of	hyperhidrosis	and	impact	on	individu-als	 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	hyperhidro-sis:	 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	treat-ment	 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 Psychia-try.	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,	 random-ized,	 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	 treat-ment	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	 compre-hensive	 approach	 to	 the	 recognition,	 diagnosis,	 and	severity-based	treatment	of	focal	hyperhidrosis:	recom-mendations	 of	 the	 Canadian	 Hyperhidrosis	 Advisory	Committee.	Dermatol Surg.	2007;33(8):908-923.	■Table 1. Randomized Controlled Trials of OnabotulinumtoxinA (Botox) Injections for the Treatment of Hyperhidrosis Area  treatedNo. of patientsFollow-up period Outcome measured ResultsAxillae3 322 4	weeks >	50	percent	reduction	in	symptoms,	based	on	HDSSImprovement	in	quality	of	life	NNT	=	2*;	P	<	.001NNT	=	5*;	P	<	.001Axillae4 320 16	weeks ≥	50	percent	reduction	in	sweat	production	from	baselineNNT	=	2*;	P	<	.001Axillae5 40 8	weeks >	50	percent	reduction	in	symptoms,	based	on	HDSSNNT	=	2*;	P	<	.001Palm6 19 28	days Gravimetric	measurement	and	subjective	rating	as	successfulNNT	=	1*;	P	<	.001Palm7 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.

Treatment of Hyperhidrosis

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Treatment of Hyperhidrosis

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