Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 • • • • • • • • 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: – 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. – 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. – Botox injection and sympathectomy are not recommended in plantar hyperhidrosis and the use of oral anticholinergics should be considered secondary to iontophoresis. – 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. – 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