Managing Hyperhidrosis: Ask Questions First

Randy Dotinga

March 15, 2021

A wide variety of medications exists for treating hyperhidrosis, a dermatologist told colleagues, but before prescribing anything to a pediatric patient, he recommended, ask the patient a simple question: "What bothers you the most?"

The answer will provide guidance for developing a step-by-step treatment strategy and help provide the patient "a set of realistic expectations in terms of what the response will look like," George Hightower, MD, PhD, a pediatric dermatologist at Rady Children's Hospital and the University of California, San Diego, said at MedscapeLive's Women's & Pediatric Dermatology Seminar.

A similar question-based approach will help guide therapy for patients with hidradenitis suppurativa (HS), he said.

With regards to hyperhidrosis, Hightower said that patients most commonly complain that their underarms are too smelly, too sweaty, and red, itchy, or painful. Causes, he said, can include irritation/contact dermatitis, folliculitis, and seborrheic dermatitis, as well as hyperhidrosis or HS.

Primary focal axillary hyperhidrosis is defined as focal, visible, excessive sweating for at least 6 months without an apparent cause plus at least two of the following characteristics: Sweating is bilateral and relatively symmetric, it impairs daily activities, it starts before the age of 25 with at least one episode per week (many patients have it daily), a family history of idiopathic hyperhidrosis is present, and focal sweating does not occur during sleep.

Secondary hyperhidrosis can be linked to other conditions, such as a spinal column injury, Hightower noted.

The first step on the treatment ladder is topical 20% aluminum chloride, which is available over the counter. This should be applied nightly for 1 week then every 1-2 weeks, Hightower recommended. All of his patients with hyperhidrosis have had at least one trial of this treatment.

The next option is daily topical treatment with 2.4% glycopyrronium tosylate (Qbrexza) cloths, approved by the Food and Drug Administration in 2018 for primary axillary hyperhidrosis in patients aged 9 years and older. According to the prescribing information, dry mouth was by far the most common treatment-associated adverse effect in clinical trials (24% vs almost 6% among those on vehicle). As for skin reactions, erythema occurred in about 17% of both the intervention and vehicle groups, and burning/stinging occurred in 14% of those on treatment and almost 17% of those on vehicle.

"If they're not able to get access to the cloths due to [insurance] coverage issues, or they don't allow them to reach the clinical endpoint desired, then I use an oral daily glycopyrrolate pill," Hightower said.

He recommends 1 mg to 6 mg daily of the anticholinergic drug, which has been used off-label for hyperhidrosis for several years. A 2012 study of 31 children with hyperhidrosis, he noted, supported the use of the drug. The retrospective study found that 90% of the patients, at a mean daily dose of 2 mg, experienced improvements, reported as major in 71%. In addition, patients experienced improvement within hours of taking the medication, and benefits disappeared within a day of stopping the medication. In the study, patients were on the treatment for an average of 2.1 years, and 29% experienced side effects, which were dose related; the most common were dry mouth in 26% and dry eyes in 10%.

According to goodrx.com, a month's supply of 2 mg of the drug costs as little as $13 with a discount or coupon.

The next steps in treatment are procedural interventions such as microwave-based therapies.

Hightower said that patients should be advised that treatment may take years, and to encourage them to return for follow-up. He suggested this helpful message: "We're still trying to find the best treatment for you, and we'll need to see you back in the office."

Hidradenitis Suppurativa

Hightower said that too often, HS goes undiagnosed for a significant period of time, preventing patients from seeing a dermatologist for treatment. Hallmarks of HS include inflammatory nodules, abscesses, and scarring, he said. "It can be disfiguring, painful, embarrassing, and associated with significantly decreased quality of life. Early recognition in terms of making and solidifying the diagnosis is important so we can prevent further worsening of the disease."

The goal of treatment include preventing scars and unnecessary emergency department visits, and stopping flares from worsening, Hightower said. For specifics, he pointed to clinical management guidelines released by the United States and Canadian hidradenitis suppurativa foundations in 2019.

Make sure to set individualized treatment goals and understand the impact of treatment on the patient's interactions with family, school, and peers, he said. And keep in mind that "parent-defined goals may be different from patient-defined goals."

Hightower reported no relevant disclosures. MedscapeLive and this news organization are owned by the same parent company.

MedscapeLive Women's & Pediatric Dermatology Seminar: It’s the Pits! Hyperhidrosis and Hidradenitis. Presented online December 11, 2020.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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