Advances in the Treatment of Hyperhidrosis - Episode 8
Dee Anna Glaser, MD: Surgical options have probably fallen by the wayside now, with these newer treatments like botulinum toxins. We think about the old days, removing an entire axillary vault, some of the lasers, or liposuction, which I used to do quite a bit in the 1990s. We just have so many more options and more options ahead of us. And so, I think these are things that really aren’t being used.
Microwave thermolysis is a treatment that I’m using in my office. It is FDA-cleared to treat axillary hyperhidrosis. One of the problems with it is that the hand piece can only be used for axilla. To date, it’s not covered under any of the insurance plans that I’m aware of, but what’s so nice about it is it is a more permanent destruction of the glands. You can get a long-term benefit from 1 or 2 treatments. That’s a real advantage for patients. But it is a procedure, and there are some potential complications such as some local anesthesia in the area, some abscess, and things like that. But I think it’s a really nice option for some patients.
In my practice, I have found that patients who have used botulinum toxins prior to using microwave thermolysis for the axilla find that the microwave thermolysis doesn’t work quite to the same degree as the botulinum toxins. But I think that it’s a really nice option. Most cities have at least 1 or 2 providers who do that in their community, and I think it’s worthwhile to talk to patients about that. There are other oral agents that we haven’t mentioned: beta-blockers, clonidine. What else do you use?
Adam Friedman, MD, FAAD: I like propranolol, especially for the person who gets sweaty when they go up on stage or while they’re in a big meeting. That’s the type of medication that you can use periodically. Anticholinergic therapy needs to be consistent and steady. A beta-blocker, you can use that here and there. I find propranolol to be very effective. However, I always have my patients do a test run at home when they’re not doing a whole lot of sitting around. I always get a baseline blood pressure on them because I don’t want to be the cause of them making a complete fool of themselves. But when done correctly, it can be very effective for a short-term fix. So, if I have a patient who’s on multiple therapies, I may throw this in as an addition—kind of as a back-up plan, if they really need it. That’s probably my go-to. I don’t use so much clonidine. I find myself using it off label more in rosacea for flushing, but it certainly works in this setting as well.
Dee Anna Glaser, MD: I would guess that you probably don’t use a lot of clonidine in the pediatric population?
Adelaide Hebert, MD: No.
Dee Anna Glaser, MD: Clonidine can be very beneficial for patients with craniofacial sweating and those with a secondary form of hyperhidrosis, as well as those who are on anxiolytics and anxiety medications. This is one of those that I do like to add for those subsets of patients. Speaking of anxiolytics, I know this is sometimes listed in that group of options. Is anybody prescribing anxiolytics for their patients with hyperhidrosis?
Adelaide Hebert, MD: Patients have come in having been prescribed anxiolytics, but they have not felt that they really got control of their hyperhidrosis. And so, they’re here for another opinion. Sometimes that’s not getting to the root of the problem. They’re not particularly anxious. They’re anxious because they sweat. Maybe their anxiety is not a primary entity. We sit and we talk with them. We educate them. I don’t really prescribe anxiolytics. I find that if we really treat the disease and help them find that home for the care of their hyperhidrosis, it takes away a lot of their anxiety. We are doing what we do best, which is being the physician who is caring for them because they have a disease state that nobody else has really embraced.
Dee Anna Glaser, MD: Yes. Are there any other kinds of things that you prescribe or that patients come in having tried? I know some of mine have tried to not drink fluids because they think they won’t sweat. Obviously, that’s the wrong approach. Are there any other crazy things that patients have tried?
Adam Friedman, MD, FAAD: Yes. We are in the age of Dr. Google. The ease of access of information is very beneficial in some respects, but it can be very detrimental. Anyone can be an expert these days, online. That said, I’ve had patients who have come in using very caustic materials, baking soda, various dilute acids. They have horrific irritant dermatitis, to the point of blistering that results in scarring and deformity in the axilla and even on the hands and feet. That’s where education is so important. A lot of patients have been suffering in silence for so long. They will do anything. If they think this is going to work, they will do anything. There are a lot of dangerous things out there. If you’re going to go with a do-it-yourself approach, make sure to confirm with an expert that it won’t cause harm. Maybe it won’t do anything, but we want to do no harm first and foremost.