Table 1.
Summary of studies and treatments
| Study | Description | Findings |
|---|---|---|
| Oxybutynin | ||
| Wolosker et al22 | Brazil Oxybutynin vs placebo Palmar, plantar, axillary HH 50 total patients, 5 lost to follow-up |
Significantly greater subjective improvement in oxybutynin group (P<0.001) |
| Wolosker et al21 | Brazil Effects of oxybutynin over 6 years Axillary HH 181 of 431 patients evaluated long-term |
At 6 weeks: 93.4% subjective improvement At 24 weeks: 82.9% continued substantial improvement Over median of 17 months: 57.4% maintained same level of improvement; 23.3% further improved; 19.4% experienced some degree of relapse (P<0.001) |
| Btx | ||
| Bushara and Park35 | Observed anhidrotic effect of Btx injections for facial spasm Craniofacial HH 3 adult patients |
Correlation between regions of injections with regions of relative anhidrosis |
| Bushara et al36 | USA Observed anhidrotic effects of Btx A injections Palmar, axillary HH 7 healthy patients: 2 patients Btx A injections into dorsal hand; 5 patients Btx A injections into one axillae |
Day 2: complete anhidrosis dorsal hand (effect persisted 11 months) Day 3: 2/5 axillae completely dry, 1/5 axillae demonstrated ↓ sweating (effect persisted 6–8 months), 2/5 axillae demonstrated no effect |
| Rosell et al20 | Sweden Btx A (Xeomin) and Btx B (Neurobloc) injections for palmar HH Btx A (Xeomin) injections for axillary HH Patients ranked treatment effects from 1 (no effect) to 5 (completely dry) Assessed DLQI |
Palmar HH group: 100% patients either 4 or 5 Axillary HH group: 95% satisfied Significant DLQI improvement in both groups at 3 weeks (P<0.05) |
| Basciani et al37 | Italy Btx B injections Palmar HH Minor’s starch iodine and weight measurement (baseline and at 4, 12, and 24 weeks after injection) |
Significant ↓ sweating both palms (P<0.001) Side effects: local pain, hand weakness |
| Lecouflet et al38 | France Btx A injections Assess safety and duration of efficacy with repeated injections Axillary HH 83 patients Approximately 11 years |
Duration of efficacy of injections significantly ↑ with time (P<0.0002) Median duration of effect: first injection 5.5 months; last injection 8.5 months |
| Lecouflet et al41 | France Btx A injections Assess safety and duration of efficacy with repeated injections Palmar HH 28 patients Approximately 11 years |
Duration of efficacy of injections significantly ↑ with time (P<0.0002) Median duration of effect: from first injection 7 months; from last injection 9.5 months |
| Surgery | ||
| Local excision | ||
| Heidemann and Licht64 | Denmark Thoracic sympathotomy vs local skin resection Axillary HH 96 patients Median follow-up 26 months Questionnaire (returned by 92% of patients) |
Symptom recurrence more common with local skin excision (51% vs 5%; P<0.001) Significantly better symptom resolution with local skin excision (P<0.001) Significantly less CH and gustatory sweating with local skin excision (25% vs 84% and 26% vs 54%, respectively; P=0.01) |
| LC | ||
| Wollina et al49 | Germany Local skin excision + SQ curettage vs tumescent LC Axillary HH 163 patients total: 37 patients received LC, 125 patients received excision with SQ curettage Minor’s starch iodine test and subjective scale |
Relapse rate at 12 months → LC group: 16.2%; excision + curettage group: 1.0% (P<0.01) Pain → LC group: 89.2% pain free; excision + curettage group: 24.0% pain free (P<0.01) Complications in LC group: mild hematoma, suture-associated irritation Complications seen only in the excision + curettage group: ↑ time required for healing, wound infections, bleeding Other benefits of LC group: ↓ time to return to work, more aesthetically sensitive scars |
| Tronstad et al14 | Norway Isolated curettage vs LC Axillary HH 22 patients total, 5 lost to follow-up SC, gravimetric measurement, VAS |
LC group → significantly lower SC (P=0.011), gravimetric measurements (P=0.028); better VAS scores for sweating (P<0.01) |
| Ibrahim et al55 | USA LC vs Btx A injections Axillary HH 20 patients Follow-up at 3 and 6 months |
At 3 months: no significant difference between LC and Btx A, but “heavy sweaters” experienced significantly greater relief from Btx A than from LC (P=0.0025) At both 3 and 6 months: greater satisfaction, more improved QOL with Btx (P=0.0002) than with LC (P=0.0017) |
| Sympathectomy and sympathotomy | ||
| Bell et al63 | Australia ETS efficacy, adverse events Palmar, axillary, and/or craniofacial HH 210 patients total, 19 lost to follow-up |
Significant improvement in all 3 groups (P<0.001): 97% palmar HH: 97%, 93% craniofacial, 71% axillary CH developed in 75% of patients Rates of severe CH: craniofacial 44.5%, axillary 26%, palmar 8% (P=0.0003) |
| Atkinson et al57 | USA Endoscopic thoracic limited sympathotomy (T1, T2 ganglia spared) Palmar, axillary, plantar HH 155 patients |
Percent improvement of sweating >3 months postoperatively: 96.6% palmar; 69.2% axillary; 39.8% plantar Long-term: palmar HH recurrence in 5 patients, severe CH in 2 patients (1.3%) |
| Heidemann and Licht64 | Denmark Thoracic sympathotomy vs local skin resection Axillary HH 96 patients total, 8% lost to follow-up Median follow-up 26 months Questionnaire (returned by 92% of patients) |
Symptom recurrence more common with local skin excision (51% vs 5%; P<0.001) Significantly better symptom resolution with local skin excision (P<0.001) Significantly less CH, gustatory sweating with local skin excision (25% vs 84% and 26% vs 54%, respectively; P=0.01) |
| Lesèche et al69 | France Relationship between extent of sympathectomy (2–5 levels) and CH occurrence Palmar and/or axillary HH 134 patients |
No significant difference in incidence and severity of CH with respect to degree of sympathectomy |
| Yuncu et al66 | Turkey Isolated T3 vs T3 + T4 sympathectomy Axillary HH 60 patients |
100% of patients (both groups) experienced both immediate and 1-year duration of HH resolution At 1-year follow-up: significantly more CH in T3 + T4 group than in isolated T3 group (100% vs 79%; P=0.008) |
| Yang et al70 | People’s Republic of China Palmar HH 163 patients total: 78 patients underwent T3 sympathicotomy, 85 patients underwent T4 sympathicotomy |
Resolution of palmar HH in all patients (both groups) No recurrence at mean follow-up 13.8±6.2 months CH incidence greater in T3 than T4 group |
| Abd Ellatif et al71 | Egypt Palmar HH 274 patients: 129 received T3 sympathectomy, 145 received T4 sympathectomy Retrospective cohort study |
CH reported in 74.4% of T3 group CH reported in 28.3% of T4 group Higher incidence of mild to moderate CH in T3 group (64.4% vs 26.9%; P=0.001) Recurrence rate similar for T3 and T4 (0.8% vs 1.4%; P=0.19) |
| Cerfolio et al72 | USA Expert consensus document |
Designation of disrupted level based on rib (R) number (R# rather than T#) Type of disruption should be explicitly noted (ablation vs resection, etc) Recommended levels for disruption of sympathetic chain based on HH type: Palmar (isolated) HH: top of R3, top of R4 Palmar, plantar, axillary HH: R4 and R5 Craniofacial HH: top of R3 |
| Miller and Force73 | USA Temporary sympathetic blockade (with bupivacaine + epinephrine) as predictor of patients likely to develop CH Palmar, axillary, plantar HH 18 patients Median 4 days |
Median 4 days follow-up: 100% symptom resolution, 12% developed CH (one of whom reported severe CH and declined ETS) Patients with mild CH after temporary blockade also experienced mild CH after ETS 100% of patients who underwent ETS were satisfied |
| Zhu et al74 | People’s Republic of China Transumbilical ETS vs traditional ETS Palmar HH 66 patients (34 transumbilical, 32 traditional) |
100% of patients reported symptom resolution Greater incidence of CH in transumbilical group (20.1%) than in traditional group (18.8%) – not statistically significant (P>0.05) Transumbilical approach associated with significantly fewer paresthesias at 1 day, 1 month postoperatively (P=0.015, P<0.001, respectively) Transumbilical approach achieved greater patient satisfaction with cosmetic outcome (94.1% vs 71.9%; P=0.036) |
| Zhu et al75 | People’s Republic of China Transumbilical ETS Palmar and/or axillary HH 35 patients 1-year follow-up |
At 1-year follow-up: 97.1% success in symptom resolution for palmar HH, 72.2% for axillary HH 94.3% satisfied with the excellence in the cosmetic outcome of the surgical incision |
| New therapies | ||
| Delivery of Btx | ||
| Andrade et al76 | Brazil Iontophoresis or phonophoresis for percutaneous delivery of Btx A Palmar HH 4 patients |
16 weeks of symptom relief after 10 daily sessions |
| Vadoud-Seyedi and Simonart77 | Belgium Btx A reconstituted in lidocaine vs Btx A reconstituted in saline Axillary HH 29 patients |
Symptom resolution in both groups Significantly less pain with injection of lidocaine-reconstituted vs saline-reconstituted preparation (29.3±20.1 vs 47.5±24.0; P=0.0027) |
| Güleç78 | Turkey Btx A reconstituted in saline + lidocaine vs Btx A reconstituted in saline alone Axillary HH 8 patients Pain (VAS) |
Symptom resolution in both groups Significantly less pain in Btx A reconstituted with saline + lidocaine (41.3±15.3 vs 63.8±16.7; P=0.026) |
| Laser technology | ||
| Goldman and Wollina82 | Brazil 1,064 nm Nd:YAG laser (no control) Axillary HH 17 patients |
Histological analysis of laser-treated skin: microvesiculation, decapitation, total vaporization of eccrine glands |
| Letada et al85 | USA Long-pulsed 1,064 nm Nd:YAG laser vs no treatment of contralateral axillae Axillary HH 6 patients |
Objective and subjective improvement in axillae treated by laser compared with control (untreated axillae) → only subjective changes determined significant (P<0.001) Histological evaluation: no differences between pre- and posttreatment |
| Caplin and Austin86 | USA 1,440 nm Nd:YAG laser (no control) Axillary HH 15 patients 1-year follow-up |
At 1-year follow-up: 72% of patients reported 2 points improvement in HDSS, 28% reported 1 point improvement in HDSS |
| Bechara et al84 | Germany Long-pulsed 800 nm diode laser vs no treatment contralateral axillae Axillary HH 21 patients |
No statistically significant difference between laser-treated and untreated axillae Both laser and control axillae demonstrated significant reduction in sweat rates (P<0.001, P=0.04, respectively) Histological evaluation: no significant changes between pre- and posttreatment |
| Microwave technology | ||
| Hong et al90 | Canada Microwave-based device (no control) Axillary HH 31 patients HDSS, DLQI, gravimetric sweat measurements Follow-up at 1, 3, 6, 12 months |
Pretreatment: 100% of patients reported HDSS of 3 or 4 Percent of patients with ≥50% ↓ in gravimetric sweat measurements: at 1 month: 90%, at 3 months: 94%, at 6 months: 90%, at 12 months: 90% At final (12-month) visit: ≥1 point ↓ in HDSS in 94% of patients, ≥2 point ↓ in HDSS in 55% of patients, average ↓ in DLQI significantly >5 points (P>0.001) Adverse events: site-related redness, swelling, discomfort, abnormal skin sensation, neuropathy, and weakness |
| Ultrasound technology | ||
| Nestor and Park93 | USA MFU-V vs sham Axillary HH First study: 16 patients total, 1 excluded due to device malfunction, 1 lost to follow-up Second study: 20 patients total, 1 lost to follow-up |
All patient pretreatment HDSS scores of 3 or 4 and ≥50 mg per 5-minute period of axillary sweat secretion (per axillae) First study: criteria for positive response: ≥50% ↓ spontaneous axillary hidrosis on 120th day, >50% of patients positive response Second study: criteria for positive response: ↓ in HDSS from 3 or 4 to 1 or 2 Positive response in 67% of MFU-V group; no response in sham group (P<0.005) Statistically significant improvement in gravimetric measurement in MFU-V group vs sham group (83% vs 0%, P<0.0001) Relationship between changes in HDSS and percent change in gravimetric analysis (P=0.005) independent of time |
Abbreviations: HH, hyperhidrosis; Btx, botulinum toxin; Btx A, botulinum toxin A; Btx B, botulinum toxin B; DLQI, Dermatology Life Quality Index; CH, compensatory hyperhidrosis; LC, liposuction–curettage; SQ, subcutaneous; SC, skin conductance; VAS, visual analog scale; QOL, quality of life; ETS, endoscopic thoracic sympathectomy; MFU-V, microfocused ultrasound coupled with visualization; HDSS, Hyperhidrosis Disease Severity Scale; vs, versus.