Hyperhidrosis treatment options update
This story appears courtesy of MDedge News
EXPERT ANALYSIS FROM COASTAL DERM
SEATTLE – After years of relying on oral anticholinergics for treating hyperhidrosis, more options have recently become available, David Pariser, MD, said at the annual Coastal Dermatology Symposium.
Hyperhidrosis is among the dermatological conditions that have the greatest impact on quality of life, and it can be particularly concerning to teens, said Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk. He referred to some new developments for an old, often misunderstood, standby: antiperspirants. “I am amazed that many people do not know the difference between an antiperspirant and a deodorant,” he said, pointing out that antiperspirants contain active ingredients – aluminum and zirconium salts – that block sweat glands, while deodorants contain a masking fragrance.
There are new-generation topical antiperspirants available over the counter, with descriptions that include “clinical strength” or “clinical protection” on the labels; they come in a box and cost about twice as much as standard products. “But they are better, and they work just as well as some of the commercial preparations,” Dr. Pariser said at the meeting, jointly presented by the University of Louisville and Global Academy for Medical Education.
One issue he highlighted was that antiperspirants are often misapplied. They shouldn’t be applied on wet skin because they react with water to create hydrochloric acid, which can irritate the skin, he said. The best time to apply an antiperspirant is right before bedtime, since it gives the salts time to clog sweat pores before sweat or water can interfere. “The plugs last for a couple of days,” so there’s no need to worry about rinsing the product off during a morning shower, he noted.
Additional therapeutic options include agents like oral glycopyrrolate, starting at a low dose (1 mg twice per day), increasing by 1 mg/day weekly until efficacy is achieved or limited by adverse events. There is also a glycopyrrolate oral solution 1mg/5ml (Cuvposa) that can be used in children.
A topical version of the anticholinergic glycopyrronium tosylate, applied using an infused cloth, was approved for treating axillary hyperhidrosis in June2018 and offers the potential for an enhanced local anticholinergic effect. Dr. Pariser, one of the authors, discussed the recently published results of two pivotal studies that found good improvement in a specially-designed quality of life endpoint (J Am Acad Derm. 2019; Jan;80:128-138.e2).
Efficacy in a subanalysis of 44 pediatric subjects (ages 9-16 years) was similar as those reported in adults, and the rate of those reporting dry mouth (24% in both age groups) was similar. Of concern was a 16% rate of mydriasis in the pediatric group, compared with 6% in the older group. One patient even wound up in the emergency room for a stroke work-up as a result, said Dr. Pariser, who is confident that the problem was caused by inadvertent exposure to the eye during application. He advises patients to avoid contact with the eyes.
Other approaches to treatment of hyperhidrosis include oxybutynin, iontophoresis, an microwave thermolysis (which may also reduce odor and hair). Endoscopic thoracic sympathectomy is effective but is the most invasive option; botulinum toxin is a minimally invasive alternative to surgery.
For those who sweat when they experience anxiety, propranolol 5-10 mg taken about 1 hour before an event that could cause hyperhydrosis can be effective, said Dr. Pariser, who recommends a test dose. “I don’t normally tell patients to try something at home. But they should try this at home” before using it prior to an important event, he added.
Dr. Pariser is a consultant and/or investigator for Dermira, Brickell Biotech, TheraVida, Atacama, TDI Surgitech, Dermavant, and Revance Therapeutics. He has not done commercial speaking, has not been on speaker’s bureaus, and has no stock or options in any company.
This publication and Global Academy for Medical Education are owned by the same parent company.
By Jim Kling