Clinicians have an expanding range of options to offer patients with persistent hyperhidrosis, Dr. David M. Pariser said at the Caribbean Dermatology Symposium.

Hyperhidrosis currently affects an estimated 7.8 million individuals in the United States. About half have axillary hyperhidrosis, and include about 1.3 million people who report hyperhidrosis that is “barely tolerable” or “intolerable,” Dr. Pariser said at the meeting, provided by Global Academy for Medical Education.

The treatment options include next generation antiperspirants that contain aluminum zirconium trichlorohydrex, which he said are more effective and less irritating than previously available products.

Although many patients apply antiperspirant as part of their morning routines, topical antiperspirants with aluminum chloride are effective when applied overnight, or for at least 6-8 hours, according to Dr. Pariser, professor of dermatology at Eastern Virginia Medical School, Norfolk, Va. To avoid irritating acid formation, patients should make sure the skin is dry before application, but if irritation occurs, he recommends that it should be washed off in the morning “before sweating begins.”

Aluminum chloride products should be applied nightly until patients see improvement, and then they can decrease the frequency of use. Concerns about a potential link between aluminum and Alzheimer’s disease stem from a 1960s study that was never successfully replicated, he pointed out.

In general, topical agents are a useful adjunct to other hyperhidrosis treatments, such as onabotulinumtoxinA, Dr. Pariser said. “Many insurance companies consider treatment of hyperhidrosis with iontophoresis or botulinum toxin medically necessary when topical aluminum chloride or other extra strength antiperspirants are ineffective or result in irritation,” he noted.

Other new topical products on the horizon for hyperhidrosis include glycopyrrolate wipes and gel, oxybutynin gel, and topical botulinum toxins, he added.

Patients suffering from generalized hyperhidrosis or hyperhidrosis of a spinal cord injury may benefit from systemic treatment, although no systemic agents are currently approved by the Food and Drug Administration for this purpose, Dr. Pariser said.

Glycopyrrolate is the preferred systemic medication for off-label hyperhidrosis treatment, and patients typically start at 1 mg twice daily, increasing the dose by 1 mg a day each week until they achieve the desired improvement or are unable to tolerate adverse effects, he said. Data also support the use of oral oxybutynin for hyperhidrosis, he noted.

Patients seeking more “permanent” treatment for hyperhidrosis might consider microwave thermolysis with an FDA-cleared device designed to stop sweating by using microwaves to destroy the eccrine glands, which do not regenerate, Dr. Pariser said. The device works by delivering microwave energy precisely in the dermal-fat interface region. Deeper tissue is unaffected, and contact cooling protects the epidermis and upper dermis.

Side effects from microwave thermolysis are usually minimal and transient, he noted. “The most common side effects are swelling and tenderness in the treated area, which can last up to a few weeks.”

By contrast, the effects of botulinum toxin on hyperhidrosis are not permanent, but patients report a high level of satisfaction and improved quality of life with this treatment option, he said. Duration of treatment varies, but data from a 16-month, randomized, double-blind trial of 207 patients showed a mean duration of 7 months between treatments.

Overall, treatment of patients with focal hyperhidrosis “leads to greater improvement of a patient’s quality of life than treatment of any other dermatologic disorder,” Dr. Pariser said. Treatments are relatively easy to learn, economically viable, and easily incorporated into a routine office practice, he said.

Dr. Pariser disclosed ties with Allergan, Dermira, Watson Labs, Ulthera, Brickell Biotech, Revance, Anterios, and Theravida.

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