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Treatment of focal axillary hyperhidrosis with neuromodulators (and non-axillary regions)


Summary and key features

  • Botulinum toxin (BoNT) is a safe, well-established, and effective treatment for focal axillary hyperhidrosis (HH).

  • Key Features Sweating is the normal physiologic response to increased body temperature and is the primary avenue of heat loss during exercise or passive heat stress.

  • HH describes excess sweating beyond what is necessary for thermoregulation.

  • HH is classified as generalized or focal.

  • The prevalence of HH is thought to be 4.8% but in teenagers it may be as high as 17.1%.

  • The starch-iodine test is a simple, colorimetric test to identify the surface area involved.

  • OnabotulinumtoxinA was approved by the US Food and Drug Administration (FDA) in 2004 for the treatment of AHH for the treatment of AHH.

  • The recommended dosing for BoNT-A is 50 units per axilla.

  • The average efficacy of BoNT-A is approximately 6 to 7 months.

  • Other regions where BoNT-A is high;y effective include palmar, plantar, craniofacial, groin, and trunk.

Introduction

Botulinum toxin (BoNT) is a safe, well-established, and effective treatment for focal axillary hyperhidrosis (HH). This chapter will present the principles and common techniques for its practical application in the clinical setting.

Sweating

Sweating is the normal physiologic response to increased body temperature and is the primary avenue of heat loss during exercise or passive heat stress. Eccrine sweat glands are found throughout most of the body, with the highest concentration in the palms, soles, forehead, and upper limbs. They are located at the junction of the dermis and subcutaneous fat and are composed of a secretory coil and duct. They control temperature by secreting an electrolyte solution in response to stimulation by the sympathetic nervous system, which facilitates thermoregulation by evaporation.

The sympathetic nervous system predominantly uses norepinephrine to activate adrenergic receptors in the body. Sweating is an exception as M3 muscarinic receptors on clear cells of the secretory coil are stimulated by the neurotransmitter acetylcholine to stimulate sweat release. Alpha- and beta-adrenergic agonists also stimulate some sweat production but to a lesser degree than acetylcholine.

Hyperhidrosis

HH describes excess sweating beyond what is necessary for thermoregulation. Patients with this condition may experience symptoms that range from mild to severe in affected areas. While it has been theorized that glandular hyperplasia or apocrine sweat glands play a role in pathogenesis, there is insufficient evidence to support this theory.

HH is classified as generalized or focal. Generalized HH typically occurs as the result of an underlying cause (secondary origin). Focal or localized HH may have a secondary origin but is more commonly idiopathic (primary). Primary focal HH is what is commonly known as “hyperhidrosis” (HH). Diagnostic criteria for HH have been suggested by a consensus panel ( Box 26.1 ). According to these criteria, two characteristics are required for making the diagnosis. Further study shows that requiring four of these characteristics for diagnosis increases specificity and positive predictive value. Evaluation and testing should be tailored by the history and review of systems. This chapter will focus on primary focal axillary HH, henceforth identified simply as axillary hyperhidrosis (AHH).

BOX 26.1
Criteria to Diagnose Primary Focal Hyperhidrosis

  • Focal, visible excessive sweating of at least 6 months duration, and

  • No apparent secondary cause, and

  • At least two of the following characteristics:

    • Bilateral and relatively symmetric

    • Age of onset less than 25 years

    • Positive family history

    • Cessation of focal sweating during sleep

    • Frequency of episodes at least once a week

    • Impairs daily activities

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