Download Bedfordshire and Hertfordshire Priorities forum statement Number

Bedfordshire and Hertfordshire Priorities forum statement
Number: 51
Subject: Botox for Focal Hyperhidrosis
Priorities Forum Guidance
Policy number: 51
Date of decision: September 2012
Date of review: September 2013
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Hyperhidrosis can be defined as excessive sweating beyond what is required to return elevated body temperature to normal1. Focal hyperhidrosis is
usually primary in origin usually affects the palms, soles, axillae and face. It is estimated that 0.6-1% of the population suffers from primary
hyperhidrosis2. As a result of the impact of this condition on quality of life it is important to treat patients effectively. There are various modalities for the
treatment of hyperhidrosis including the use of Botulinum toxin (Botox) injections, working through inhibiting the release of acetylcholine at the
presynaptic membranes of sympathetic nerves that are involved in sweating. An extensive literature search of English language articles published from
1990 to 2008 reveals:
The Hyperhidrosis Disease Severity Scale (HDSS, a four point scale-see appendix 2) should be used as a measure of disease severity as it can be
rapidly administered and has been validated against other dermatology questionnaires.
Placebo controlled trials and observational studies show that the use of Botox injections in axillary hyperhidrosis can reduce excessive sweating (by
50% or more) in up to 90% of patients. The recommended dosage by review articles is 50 units per axilla. It was also noted to be effective to improve
quality of life measures with the duration of these outcomes lasting between 6-12 months.
For palmar hyperhidrosis the use of Botox versus placebo showed significantly greater reduction in sweating (gravimetric measurement) without
concomitant decrease in grip or dexterity (some studies have shown decreased finger pinch with higher doses of Botox). The main side effect reported
has been pain during injection in a highly innervated area and therefore proper use of anaesthesia (anaesthetic blockade is preferable to topical
anaesthesia) is vital to success of tretament4. Endoscopic thoracic sympathectomy (ETS) is particularly successful in palmar hyperhidrosis (success
rate 92-99% with significant side effects including compensatory sweating in 24-100%). Patients should make an informed choice between the two.
There is less evidence to suggest that Botox injections are useful in plantar hyperhidrosis although if both palmar and plantar co-exist injection in the
palms has been shown to reduce sweating in both. It is very rare however to have plantar hyperhidrosis in isolation. Sympathectomy is not used for
plantar hyperhidrosis due to side effects.
Botox injections are the treatment of choice for Frey’s syndrome (facial hyperhidrosis secondary to parotidectomy) and can be used for other forms of
facial hyperhidrosis. Oral anticholinergic medication can also be used. ETS should only be considered as a last resort.
The cost for initial treatment with Botox (doctor led) would be £150 with subsequent nurse led sessions costing £120. Endoscopic Thoracic
Sympathectomy based on a 1 day stay costs £1,283.
Based on the literature review and costs it is recommended that at the primary care level GPs should assess disease severity (using the HDSS). If the
score is 1-2 advice and topical treatments (aluminium chloride deodorants) should be given. If the score is 3-4 and topical treatment is unsuccessful
referral to secondary care should be made where upon treatment differs according to site of hyperhidrosis:
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Botox injections (50U per axilla) are the first line of treatment. If it is successful it should be repeated in discussion between patient and clinician
and at the clinician’s discretion. If unsuccessful on first attempt, another attempt should be made using Botox. If this is unsuccessful patients
should be offered ETS as the next line of treatment.
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For both palmar and plantar hyperhidrosis the first line of treatment in secondary care is iontophoresis. If this is not successful for palmar
hyperhidrosis the patient should make an informed choice between Botox injections and ETS understanding the main side effects of pain and
compensatory sweating respectively.
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Botox injection and sympathectomy are not recommended in plantar hyperhidrosis and the use of oral anticholinergics should be considered
secondary to iontophoresis.
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Botox injection is recommended as a first line treatment for Frey’s syndrome (100U or 50U/cm2) and can be used in conjunction with or instead
of oral anticholinergic medication.
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These pathways can be seen in appendix 1-5.
Appendix 1
Focal Hyperhidrosis
Pathway in Primary Care
History and Diagnosis
(exclude generalised hyperhidrosis and refer if necessary)
Assess site and severity (use HDSS)
If HDSS 3-4 advise and start local treatments
(aluminium salts)
If HDSS 1-2 advise and start local treatments
(aluminium salts)
Successfully controlled after 2 months
Unsuccessfully controlled after 2 months
Continue and review regularly
Refer to Dermatology or other appropriate specialty
Appendix 2
Secondary Care: Axillary Hyperhidrosis
Assess severity (HDSS) and area (Minor iodine)
Botox injection-50U per axilla (1)
Successful-50% reduction in sweating
(reduction of 1-2 on HDSS at 2 weeks)
No: repeat Botox injection once more
(interval 16 weeks)
Yes: repeat Botox injection on patient request if
sweating back to 50% baseline (interval 16 weeks)
Unsuccessful: proceed to ETS
Repeat injections should be based on discussion
with patient and clinical discretion
Appendix 3
Secondary Care: Palmar Hyperhidrosis
Assess severity (HDSS)
and area (Minor iodine)
Iontophoresis
*Good patient information required for
informed consent
Successful-50% reduction in sweating
(reduction of 1 on HDSS at 2 weeks)
No
Botox injection: 150-200U/palm
(with appropriate anaesthesia)*
Yes: Continue
Endoscopic Thoracic Sympathectomy*
Appendix 4
Secondary Care: Plantar Hyperhidrosis
Assess severity (HDSS) and area (Minor iodine)
Iontophoresis
Successful-50% reduction in sweating
(reduction of 1on HDSS at 2 weeks)
No: consider oral medications
(anticholinergics)
Consider Botox if palmoplantar hyperhidrosis
(injection should be in palm)
Yes: Continue
Appendix 5
Secondary Care: Craniofacial Hyperhidrosis
Assess severity (HDSS)
and area (Minor iodine)
Botox injection100 units or 0.5U/cm2
Botox is choice for Frey’s syndrome)
Oral medication (anticholinergics)
ETS should only be considered as a last resort