Patient Concerns, Goals Guide Hyperhidrosis Therapy

LAS VEGAS — Effective treatment for hyperhidrosis begins with knowing what matters most to the patient, then establishing reasonable expectations and treatment goals, experts said here.

Most patients have more than one body area affected by hyperhidrosis. Homing in on the one that’s most important to the patient can guide and help optimize treatment, said Dee Anna Glaser, MD, of the Saint Louis University School of Medicine.

“The way I start is to try to figure out what bothers the patient most,” Glaser said at the Fall Clinical Dermatology Conference. “I do that by asking the patient, ‘If I can treat one area on you, what would you choose?’ It’s remarkable, but they have that one area, and sometimes it’s very different from what I think they might choose.”

Whenever possible, Glaser begins treatment with focal, specifically targeted therapy and then communicates to the patient about reasonable expectations and treatment goals.

“It’s important to set expectations upfront,” she said. “Let them know they will continue to sweat. They will not be fully dry. Set expectations so that they know we are going to take them from really intolerable sweating or mildly intolerable sweating down to more tolerable and more reasonable amounts of sweating.”

Clinicians and their patients have more treatment options than ever, but all of them have limitations. As a result, “mixing and matching” will be unavoidable.

Antiperspirants Have a Role

Glaser recommends antiperspirants for all of her patients with hyperhidrosis. Newer, clinical-strength products control sweating better than the older nonprescription products. The newer products are recommended for use at bedtime or twice daily, and they can be combined with prescription-strength aluminum chloride.

Aside from antiperspirants, currently used treatments for hyperhidrosis include single-use glycopyrronium cloths (Qbrexa), iontophoresis, botulinum toxin, microwave therapy, systemic agents, sweat gland resection, and endothoracic sympathectomy.

Increasingly, Glaser turns to systemic therapies when patients do not get the desired results with topical therapies. Multiple have been tried with varying degrees of success, including anticholinergics, benzodiazepines, beta-blockers, the calcium antagonist diltiazem, the alpha agonist clonidine, and the nonsteroidal anti-inflammatory drug indomethacin. None of the agents has an approved indication for hyperhidrosis, and data on efficacy and long-term safety are limited or nonexistent in some cases.

Glaser most often prescribes the anticholinergics glycopyrrolate and oxybutynin. As a class, anticholinergics are associated with a number of side effects, the most common being dry mouth. The drugs are contraindicated for patients with glaucoma, impaired gastric emptying, or a history or symptoms of urinary retention.

“We’re trying to decrease the sweating, not any of the side effects, so this requires starting with some very low doses and then escalating as you go further,” she said.

Common candidates for oral anticholinergics are patients with multiple areas of involvement, and Glaser combines the anticholinergic with another treatment. She hesitates to use anticholinergics in certain patients who have a predisposition to sweating, beyond the hyperhidrosis: athletes, people with outdoor jobs, and children.

Patients with multifocal hyperhidrosis require combination therapy. Glaser often combines an anticholinergic with a focal therapy. She may prescribe propranolol for event-based sweating, as needed. She does not combine topical and systemic anticholinergic agents.

Glycopyrronium cloths are the newest FDA-approved treatment for hyperhidrosis and can be used by adults and children. The cloths are designed for nightly application to the axilla. They are non-occlusive, do not require hair removal, and can be used with a nonprescription antiperspirant or deodorant in the morning. Improvement in sweating may be observed within a week, but most patient see results within 2 or 3 weeks, said Glaser.

Unique Considerations for Kids

The cloths, or towelettes, have proved to be especially helpful for children with hyperhidrosis, said Adelaide Hebert, MD, of UTHealth in Houston. A recent post hoc analysis of two phase III randomized trials showed that the towelettes led to symptom improvement in pediatric patients as early as 1 week after starting treatment. Dry mouth was the most commonly reported adverse event, occurring in 17%-24% of patients. Additionally, erythema/redness occurred in 17% and burning/stinging in 14%.

“The results showed significant improvement in disease severity and that the treatment was well tolerated,” said Hebert. “Side effects were primarily anticholinergic. Long-term safety and efficacy results are pending.”

An emerging topical anticholinergic for pediatric hyperhidrosis is sofpironium bromide gel. Developed for axillary hyperhidrosis, the treatment led to statistically significant and clinically meaningful improvement in hyperhidrosis severity in a preliminary clinical trial involving pediatric patients with hyperhidrosis.

None of the patients discontinued treatment because of side effects, and pharmacokinetic studies showed minimal or no detectable drug in the patients, said Hebert.

Another emerging therapy is the oral anticholinergic THVD-102, which contains oxybutynin in combination with pilocarpine, a drug that helps reduce the side effect of dry mouth.In preliminary clinical studies, the drug reduced sweating and the frequency of anticholinergic-induced dry mouth, Hebert said.

Ongoing studies of hyperhidrosis therapies include evaluations of the glycopyrronium towelettes for palmar hyperhidrosis. sofpironium bromide gel for axillary hyperhidrosis, topical umeclidinium for axillary hyperhidrosis, ANT-1403 (a botulinum toxin agent) for axillary hyperhidrosis, and hydrogel-based iontophoresis.

Pediatric patients pose some unique considerations with regard to hyperhidrosis, said Hebert. The younger age at onset, variable distribution of sweating, and the impact on school, self-confidence, and lack of approved therapies set pediatric patients apart from the adult population with hyperhidrosis.

Current treatment options consist of clinical-strength antiperspirants and off-label prescribing of glycopyrrolate, oxybutynin, or iontophoresis. Hebert highlighted one study of oxybutynin for palmar/plantar hyperhidrosis in children, showing >90% improvement in both quality of life and level of sweating in a patient population age <14 years.

Pediatric patients with hyperhidrosis differ from adults, she said. Almost all of them sweat from two or more focal areas, and the average is five. A study of the impact of hyperhidrosis on adolescents showed that 75% reported moderate or major impairment from daily excessive sweating. The condition can lead to social ostracizing and have an extremely detrimental impact on a child’s development of self-confidence.

“Even your youngest patients can suffer with hyperhidrosis,” said Hebert. “It can cause unique challenges for children developing their own sense of self and self-confidence. We want to offer them the right therapies, for the right reasons, that fits in with their lifestyle and has the fewest side effects.”

last updated 10.21.2019