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Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director Dermatology Clinical Trials Unit Emory University School of Medicine April 1,2017

Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

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Page 1: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Don’tsweatit:treatmentsforhyperhidrosis

ZakiyaP.Rice,MD,FAAD,FAAPAssistantProfessorofDermatologyandPediatrics

DirectorDermatologyClinicalTrialsUnitEmoryUniversitySchoolofMedicine

April1,2017

Page 2: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

ExternalIndustryRelaMonships*

CompanyName Role

Equity,stock,orop/onsinbiomedicalindustrycompaniesorpublishers

None

BoardofDirectorsorofficer

CoquilleEconomicDevelopmentCorp(CEDCO)Mith-ih-kwuhEconomicDevelopmentCorp(MEDCO)

WilliamS.RiceMPA,Husband,BoardMember

Royal/esfromEmoryorfromexternalen/ty

None

IndustryfundstoEmoryformyresearch

Sanofi-Genzyme/RegeneronPharmaceu/cals,Inc.(AD)AnacorPharmaceu/cals,Inc.(AD)CelgenePharmaceu/cals,Inc.(AD/PsO)Menlo(CP)Incyte(Vi/ligo)Galderma(PsO)Merck&Co.(Neurology)AbbVie(Neurology)Janssen(Neurology)

PrincipalInves/gator(PI)PIPI/Co-Inves/gator(CI)PI(par/alsalarysupport,PSS)CI(PSS)CI(PSS)CI(PSS)CI(PSS)CI(PSS)

Other PierreFabreGlobalPointeHealthprac/ceStatelineFilmsGeorgiaPhysiciansAssistantsSocietyCNNInterna/onalHyperhidrosisSociety

HonorariumHonorariumHonorariumHonorariumHonorariumHonorariumHonorarium/Dis/nguishedFaculty

Page 3: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

ObjecMves

1)  Reviewthequalityoflife(QoL)impactofhyperhidrosis(HH)

2)  ReviewtheknownpathophysiologyofHH3)  ReviewthetreatmentopMonsforHH

Page 4: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Outline

DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH

Page 5: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Outline

DefiningHH(reviewingclassifica/on)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH

Page 6: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

ID:A21yearoldfemaleHPI:8yearhistoryofexcesssweaMngofherpalmsbilaterallyMEDS:NONEROS:NegaMve

www.miamidermlaser.com.AccessedSept1,2015.

Page 7: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#1Herdiagnosisismostconsistentwith:A)  GeneralizedHHB)  RegionalHHC)  PrimaryfocalHHD)  AquagenicpalmarkeratodermaE)  Noneoftheabove(thisisdegreeofsweaMng

isnormal)

Page 8: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

WhatisHyperhidrosis?

Swea%ngthatismorethanrequiredtomaintainnormalthermalregula%on

Hornbergeretal.JAAD.2004.

Page 9: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.hyperhidrosisuk.org.AccessedSept1,2015.

Page 10: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

DiagnosisofPrimaryFocalHyperhidrosis

•  Focal,visible,excessivesweaMngofatleast6monthsduraMon,withoutapparentcause,withatleast2ofthefollowingcharacterisMcs:– BilateralandrelaMvelysymmetric–  ImpairsdailyacMviMes– Frequencyofatleastoneepisodeperweek– Ageofonsetlessthan25years– PosiMvefamilyhistory– CessaMonoffocalsweaMngduringsleep

Hornbergeretal.JAAD.2004.

Page 11: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Primaryvs.Regionalvs.Generalized

Type Clinicalpresenta/on Causes

PrimaryFocalHH Focal,bilateral,symmetricsweaMng Idiopathic

SecondaryFocalHH FocalsweaMng,asymmetrical Neurologicaldisorders(i.e.Freysyndrome),NeoplasmsTrauma

GeneralizedHH GeneralizedsweaMng Endocrinedisorders(i.e.Pheochromocytoma,thyrotoxicosisetc.)DrugsTumorsFebrilediseasesSpinalcordsinjuryCutaneousdiseases

Glaseretal.Cu6s.2007.

Page 12: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Aquagenicpalmarkeratoderma

Page 13: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Outline

DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH

Page 14: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.cancer.penmedicine.org.AccessedSept1,2015.

Page 15: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#2WhatistheprevalenceofHH?

A)  0.03%B)  1%C)  2.8%D)  10%E)  28%

Page 16: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

PrevalenceofHH

•  2.8%oftheUnitedStatesPopulaMon(7.8million)– Comparabletopsoriasis– UnderesMmate(widelyundiagnosedanduntreated)

Strueonetal.JAAD.2004.

Page 17: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

PrevalenceofHH(Cont.)

•  2/3rdofHHpaMentsdonotconsulttheirphysician

•  HHpaMentswaitforameanof8.9yearsbeforeseekingtreatment– NotknowingtreatmentopMons– NotabletofindaproviderfamiliarwithHHtreatmentopMons

– NotknowinginsurancecoverageopMons– Embarrassment

Wallingetal.JAAD.2009.

Page 18: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Outline

DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH

Page 19: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

“Neverletthemseeyousweat!”

www.huffingtonpost.com.AccessedSept.1,2015.

Page 20: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.huffingtonpost.com.AccessedSept.1,2015.

Page 21: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.telegraph.uk.com.AccessedSept.1,2015.

Page 22: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.businessinsider.com.AccessedFebruary26,2017.

Page 23: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director
Page 24: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director
Page 25: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QoLinHH

“Iusuallywearblackandtrynottolimmyarms.”“Myfeetarealwaysinfectedwithfungusandaresore.”“Mypenslipsoutofmyhandsandmypaperisalwayswet.”“Iamnotabletoplaybaseball(myfavoritesport)becausethebatfliesoutofmyhands”“Ihavenottakenajoboutsidemyhouse.”“IwoulddoanythingtoimprovemysweaMng!”

Page 26: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.Mmeforhealthcare.org.AccessedSept1,2015.

Page 27: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.chir.it.AccessedSept.1,2015.

Page 28: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.shoesqueta.atspace.co.uk.AccessedSept.!,2015.

Page 29: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QoLinHH(Cont.)Condi/on DermatologyQualityLifeIndex

Hyperhidrosis 10.1

Severeacne 9.2

Pruritus 9.2

Psoriasis 8.9

AtopicDermaMMs 7.3

Hailey-Hailey 6.1

Darier’sDisease 5.9

ViMligo 4.8

Swartlingetal.EJNeurol.2001.

Page 30: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Outline

DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH

Page 31: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#3

TheunderlyingpathophysiologyofHHisduetoan:

A)  IncreaseddensityofeccrineglandsB)  IncreasedsizeofeccrineglandsC)  IncreasedacMvityoftheeccrineglandsD)  Increasedreleaseoftheacetycholine(ACh)E)  IncreaseduptakeoftheACh

Page 32: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

PathophysiologyofHH

•  Poorlyunderstood•  Normaldensityandsizeofeccrineglands•  Overs/mula/onoftheeccrineglandsinnervatedbypostganglioniccholinergicsympathe/cfibers

Satoetal.JAAD.1989.Loweetal.BJD.2004.

Page 33: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

•  CartoonofpostsynapMcclem

Eccrinecell

www.gi.jhsps.org.AccessedSept1.2015.

Page 34: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

PathophysiologyofHH(Cont.)

•  ProbablygeneMc– Geneunknown– AD,variablepenetrance– 30-50%haveaknownfamilyhistoryofHH

Haideretal.CMA.2005.

Page 35: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Outline

DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH

Page 36: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#4

TopicalanM-perspirantsmechanismofacMon(MOA)is:

A)  PhysicalblockadeofeccrineductsB)  DecreasedreleaseofAChC)  IncreaseddestrucMonofAChD)  DecreaseduptakeofAChE)  Thermolysisofeccrinecells

Page 37: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHHNon-invasive Minimally

invasiveModeratelyinvasive

Surgical

TopicalmedicaMonsSystemicmedicaMons

IontophoresisBotulinumtoxininjecMons

MicrowaveThermolysis

ExcisionLiposucMonSympathectomy

M*PO

Page 38: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  Topical– Aluminum/Zirconiumsalts– UsedalllocaMons,mosteffec/veaxillae

Page 39: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.hyperhidrosisnetwork.com.AccessedSept1,2015.

Page 40: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#5

ThemostcommonsideeffectameruseoftopicalanM-perspirantis:

A)  IrritaMonB)  DryeyesandmouthC)  MuscleparalysisD)  DysesthesiaE)  Compensatoryhyperhidrosis

Page 41: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

M+nCl+nmolesBaseàM(base)3ppt+nHClBasemaybeOHfromwater,lactate,orproteinBestappliedtodryareaintheeveningbeforebed.

Page 42: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#6

Glycopyrrolate’sMOA:

A)  PhysicalblockadeofeccrineductsB)  DecreasedreleaseofAChC)  IncreaseddestrucMonofAChD)  DecreaseduptakeofAChE)  Thermolysisofeccrinecells

Page 43: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  SystemicmedicaMons– An/cholinergics(glycopyrrolate>>oxybutynin)– Beta-blockers– CalciumChannelBlockers– Alphaandrenergics– Benzodiazepines

Page 44: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

•  CartoonofpostsynapMcclem

Eccrinecell

www.gi.jhsps.org.AccessedSept1.2015.

Page 45: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  SystemicanMcholinergicsarebesttouse:– GeneralizedHH– MulMpleareasofinvolvement– Largeareasofinvolvement– Craniofacial– MulM-therapyapproachwithotheragents

Page 46: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#7

ThemostcommonsideeffectamertheuseofasystemicanMcholinergicis:

A)  IrritaMonB)  DryeyesandmouthC)  MuscleparalysisD)  DysesthesiaE)  Compensatoryhyperhidrosis

Page 47: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  AnMcholinergicsideeffects– Ocular:Dryeyes,mydriasis,cycloplegia– GI:Drymouth,reducedgastricsecreMons– RESP:BronchodilaMon,reducedsecreMons– GU:UrinaryretenMon(relaxessmoothmuscleuretersabladderwall)

– CARD:Cardiacarrythmias(bradycardiaatlowdosesandtachycardiaathighdoses)

Palleretal.JAAD.2012.

Page 48: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  AnMcholinergicContraindicaMons– Absolute•  Glaucoma•  Impairedgastricemptying•  UrinaryretenMon

Page 49: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  AnMcholinergiccauMon– OutdooroccupaMon/athlete– PediatricpaMents–  Age>65yearsold•  SystemicanMcholinergicsassociatedwithdemenMa

Grayetal.JAMAInternalMed.2015.

Page 50: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#8TheMOA

ofiontophoresisis:A)  PhysicalblockadeofeccrineductsB)  DecreasedreleaseofAChC)  IncreaseddestrucMonofAChD)  DecreaseduptakeofAChE)  Thermolysisofeccrinecells

Page 51: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  Iontophoresis– Passingofionizedsubstancethroughintactskinbyuseofelectricalcurrent

– Forprimaryfocalpalmar/plantarHH•  Oneofthebestop/ons

Page 52: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.rafisher.org.AccessedSept.1,2015.

Page 53: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  MOAofIontophoresis– BlockageofsweatglandsfromiondeposiMon– BlockingofsympatheMcnervetransmission– DecreaseinpHduetoaccumulaMonofhydrogenions

Hilletal.Cu6s.1981.Anlikeretal.CurProbDermatol.2002.Wangetal.Br.J.Dermatol.1994.

Page 54: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#9

Themostcommonsideeffectamertheuseifiontophoresisis:

A)  IrritaMonB)  DryeyesandmouthC)  MuscleparalysisD)  DysesthesiaE)  Compensatoryhyperhidrosis

Page 55: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  AdverseeventsfromIontophoresis– SMnging/Mngling/“pinsandneedles”duringtreatment

– Erythemaalongthewaterlineofthehand– DermaMMs,vesiculaMon

Page 56: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#10TheMOA

ofbotulinumtoxin(BTX)is:A)  PhysicalblockadeofeccrineductsB)  DecreasedreleaseofAChC)  IncreaseddestrucMonofAChD)  DecreaseduptakeofAChE)  Thermolysisofeccrinecells

Page 57: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

EccrinecellEccrinecell

www.gi.jhsps.org.AccessedSept1.2015.

Page 58: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

www.microbewiki.kenyon.AccessedSept1.2015.

Page 59: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  BTXA– OnabotunilumtoxinA(Botox®)•  FDAapprovedJuly19,2004forsevereprimaryaxillaryHH

– AbobotulinumtoxinA(Dysport®)•  NotFDAapprovedforHH

–  IncobotulinumtoxinA(Xeomin®)•  NotFDAapprovedforHH•  Maybestoredatroomtemperature

Loweetal.JAAD.2007

Page 60: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  InjecMonsofBTX– Officeprocedure– PaingaMngtechniques– Craniofacial,axillary,palmar,infra-mammary,groin,plantar

– Q4-6months

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TreatmentofHH

www.emedicine.medscape.org.AccessedSept1.2015.

Page 62: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

•  100unitsofBotox®•  Dilute4mlsterileNS•  2.5unitsper0.1ml

Page 63: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

•  30gauge,1mlsyringe•  1.5-2cmapart•  2.5unitstoeachsite

www.emedicine.medscape.org.AccessedSept1.2015.

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Videos

hep://www.sweathelp.org/educaMon-and-resources/online-learning.html

Page 65: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#11

AworrisomesideeffectamertheuseofBTXforpalmarHHis:

A)  IrritaMonB)  DryeyesandmouthC)  MuscleparalysisD)  DysesthesiaE)  Compensatoryhyperhidrosis

Page 66: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  BTXsideeffects–  InjecMonsitepain–  InjecMonsitebleeding– CompensatoryHH– Muscleweakness(craniofacialandpalmar)

Page 67: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMon#12TheMOA

ofmiraDryis:A)  PhysicalblockadeofeccrineductsB)  DecreasedreleaseofAChC)  IncreaseddestrucMonofAChD)  DecreaseduptakeofAChE)  Thermolysisofeccrinecells

Page 68: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  miraDrySystem– ManufacturedbyMiramar

•  AxillaryHH(andhairremoval)•  FDAapprovedJanuary2011•  Usesmicrowaveenergy(580MHz)resulMnginthethermolysisofeccrineglands

www.westcoderm.com.AccessedSept1.2015.

Page 69: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH

•  miraDrysideeffects– Dysethesia(transientalteredsensaMonintreatmentarm)

– Localswelling– Compensatoryhyperhidrosis(rare)– $3K

Glaseretal.DermSurg.2012.

Page 70: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentHH

•  AddiMonaltopicals– Astringents(formaldehyde,gluteraldehyde,tannicacid,aceMcacid)

– Glycopyrrolate(wipesandgel)*– Oxybutynin– Botulinumtoxins

*AvailableCanadaBergstresseretal.IntlJDermatol.2002www.clinicaltrials.gov

Page 71: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

Inves/ga/onalAn/cholinergicTopicalGelMayBeSafe,Effec/veForTreatmentOfAxillary

Hyperhidrosis,StudySuggests

•  Medscape(3/9,Tucker)reportsthatresearchpresentedattheAmericanAcademyofDermatologymeeMngsuggested“aninvesMgaMonalanMcholinergictopicalgelissafeandeffecMveforthetreatmentofaxillaryhyperhidrosis.”Thegel,Sofpironiumbromide(BBI-4000),“isaspeciallyformulated‘som’topicalanMcholinergicdesignedtoblocksweatproducMon,anditsrapidmetabolicdeacMvaMonandexcreMonreducestheadverseeffectsassociatedwithanMcholinergicagents.”

Page 72: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

ObjecMves

1)  Reviewthequalityoflifeimpactofhyperhidrosis(HH)

2)  ReviewtheknownpathophysiologyofHH3)  ReviewthetreatmentopMonsforHH

Page 73: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

PaMentswith

hyperhidrosisareaJOYtocarefor!

Page 74: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

hep://www.sweathelp.org/

DiagnosisandtreatmentalgorithmsInformedconsentsVideosBrochuresandpostersClinicalresearchposMngsCPTandICD-10codes(insuranceleeers)LiteraturereferencesAndMUCHMORE…

*Ms.LisaPiere|

Page 75: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

QuesMons:[email protected]

Page 76: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

TreatmentofHH•  Glycopyrrolate(PO)– Adults

•  1and2mgtablets•  Start1mgPOBID•  Increase1mgevery2weeks,dependingonclinicalsideeffects

•  Max8mg/day–  Children

•  Oralsuspension0.5mg/mL•  Start0.02mg/kgPOTID•  Increase0.02mg/kgevery1-4weeks,dependingonclinicalsideeffects

•  Max3mg/day

Page 77: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

BillingandCoding•  E&M99212-99213•  ICD-10PrimaryFocalHyperhidrosis•  L74.512axilla•  L74.513palms•  L74.514soles•  R61Craniofacial•  CPT

–  97033,iontophoresis,each15min•  Typicallybillfor2-4units,dependingonhowmanyareasaretreated

–  64650chemodenervaMonofeccrineglands,axillae–  64653chemodenervaMonofeccrineglands,otherareas(i.e.scalp,

face,neck),–  64999unlistedprocedure,nervoussystem(i.e.handsandfeet)

•  J0585,perunitofonabotulinumtoxinA

Page 78: Don’t sweat it: treatments for hyperhidrosis...Don’t sweat it: treatments for hyperhidrosis Zakiya P. Rice, MD, FAAD, FAAP Assistant Professor of Dermatology and Pediatrics Director

HDSSHowwouldyourateyourHH Score

SweaMngnoMceable,neverinterferes 1

SweaMngtolerable,someMmesinterferes 2

SweaMngbarelytolerable,frequentlyinterferes 3

SweaMngintolerable,alwaysinterferes 4


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