Hyperhidrosis

Who can refer:

GP authorised referral only

Who to refer:

Patients who have failed the recommended Primary Care Management can be considered for referral, though please take into account the information below.

How to refer:

SCI routine dermatology

Referral for Botox

If after appropriate primary care management has failed, botox can be considered but referrals have had to be declined at the time of writing as the service is overwhelmed. Referrals may be accepted in the future and the service will inform GPs in that case.

Referral for iontophoresis

The current waiting list (2020) for a loan of a home unit (for a 2 week period only) is very lengthy and if patients find it does work for them, they will still have to self fund their own machine. Therefore, we currently recommend patients consider buying their own machine.

Successful treatment requires seven sessions over a four week period initially to get the hyperhidrosis controlled and then requires top-up treatments as needed which varies from every week to every two weeks. It usually takes at least four sessions before there is any noticeable reduction in sweating. Each treatment session takes about 20 minutes for the hands and 30 minutes for the feet.

There are a variety of home iontophoresis machines available ranging in price from £200 to more than £400. Patients purchasing a unit for personal use should be exempt from paying VAT. It is important to encourage patients to look for companies who offer a full refund within a few months of purchase if it does not work for them. Demonstration DVDs are also available for patients who may choose to buy a machine and this may not require any further input from a health professional.

Further information and options for patients can be found  https://hyperhidrosisuk.org/treatment-options/iontophoresis/. 

Referral for onward consideration for surgery

Patients with severe, treatment refractory palmar hyperhidrosis may be considered for selective sympathectomy (T2-T3 ganglia). The result is not permanent, but typically lasts for years. The most common adverse effect is compensatory sweating, which occurs in up to 80% of patients (in up to 3% it can be severe and debilitating).

Referral should be to Dermatology in the first instance who can then make onward referral for surgery if appropriate

Consider the differential diagnosis of generalised excessive sweating!

Infective: acute viral or bacterial infections; chronic infections, such as tuberculosis, malaria, brucellosis

Drugs: See www.sweatsolutions.org/SweatSolutions/Downloads/Diaphoretic_Drugs.pdf  SSRIs are the most common offenders.

Endocrine: diabetes, hyperthyroidism, menopause, pregnancy, carcinoid syndrome, hyperpituitarism, pheochromocytoma, acromegaly.

Neurological disorders: stroke, spinal cord injuries, gustatory sweating after parotidectomy, Parkinson’s disease.
Other: lymphoma and other myeloproliferative disorders, congestive heart failure, anxiety, obesity

Initial treatment in primary care should include lifestyle advice as well as topical agents.

Axillary hyperhidrosis

It’s standard practice to first try aluminium chloride hexahydrate 12% or 20% solution preparations as per LJF.

Their use is often limited by irritancy, and it’s worth emphasising the need to apply to a bone dry surface just before bed. 

Odaban® spray (20% aluminium chloride in a silicone base) applied with makeup remover pads can be purchased by the patient if solutions are too irritating. The response is maximal by six weeks. Disposable underarm pads are worth trying also, especially if the patient wears a uniform at work. Details for purchase are on the Hyperhidrosisuk.org website.

Topical glycopyrrolate cream, lotion or solution is also available, and appears to be more effective on craniofacial sites. It doesn’t work well for axillary hyperhidrosis in our experience. Glycopyrromium bromide (Glycopyrrolate) is on the Additional List of the Joint Lothian Formulary so can be prescribed in primary care on specialist advice.

Palmo/plantar hyperhidrosis

• LJF formulary: Aluminium chloride hexahydrate 12% or 20% solution applied each night and washed off in the morning.

Branded preparations that the patient can purchase include:

• Odaban® Foot Powder (20%) 
• Perspirex® Foot Lotion (25%)   
• SweatStop® Forte Max Foot Antiperspirant Spray
• Iontophoresis (see referral advice for more info on home machines)
•  

Botox injections under Entanox anaesthesia is very effective for palmar hyperhidrosis but currently (2019) dermatology is not funded to do this.

Craniofacial

• Cautious trial of aluminium chloride hexahydrate solution can be considered, but it can be difficult for facial skin to tolerate.

• Odaban® spray applied with make up remover pads can be helpful (patient would need to purchase)
• Glycopyrrolate may be helpful on specialist advice.
• Oral agents as below may be required in more severe cases.
• Propantheline
  • 15mg TDS one hour before meals
  • Licenced
  • Short half-life
  • Dry mouth a side effect
• Oxybutynin slow release:
  • 5mg OD initially, then increase by 5mg per week to max 20mg OD
  •  Dry mouth a side effect.
• Glycopyrrolate
  • On specialist advice – letter from dermatology available for further information
• Clonidine (not antichonlinergic, stimulates inhibitory sympathetic α₂ receptors)
  • Consider 0.1mg BD if above intolerable or contraindicated
  • Drowsiness main side effect

For Patients

• www.hyperhidrosisuk.org offers patients a wider understanding of hyperhidrosis and how to manage it.
• www.sweathelp.org
• http://www.bad.org.uk/library-media/documents/Hyperhidrosis Update Apr2014-lay reviewed Mar2013.pdf

For Health Professionals

• https://www.sweathelp.org/medical-professional-resources.html
• http://www.pcds.org.uk/clinical-guidance/hyperhidrosis
• https://www.sweathelp.org/treatments-hcp/clinical-guidelines/hyperhidrosis-treatment-algorithms.html