Download Focal Hyperhidrosis - South Devon and Torbay CCG

Northern, Eastern and Western Devon Clinical Commissioning Group
South Devon and Torbay Clinical Commissioning Group
Clinical Policy Committee
Commissioning policy: treatment of focal hyperhidrosis
Treatments for focal hyperhidrosis are commissioned in the following circumstances:
Topical aluminium Chloride preparations may be prescribed for patients with a
Hyperhidrosis disease severity score of 2 or greater (sweating is tolerable but
sometimes interferes with daily activities).
In patients with a Hyperhidrosis Disease Severity Scale score of 3 or more (sweating
which is barely tolerable and frequently interferes with daily activities) which has
failed to respond to treatment for at least one month with topical aluminium, the
following specialist services are commissioned through direct referral to the
department of dermatology:
Systemic oral anticholinergic drugs
Iontophoresis
Patients with palmoplantar hyperhidrosis
Botulinum toxin is commissioned for use in patients with palmoplantar hyperhidrosis
who have not achieved a 50% reduction in sweat production with the above
treatments. Botulinum toxin is commissioned for use in patients with axillary
hyperhidrosis in whom the above treatments have proven unsuccessful and who
have a resting sweat production per axilla of greater than 50mg in 5 minutes.
Surgical treatment with endoscopic thoracic sympathectomy for severe resistant
axillary or palmar hyperhidrosis may be offered with explanation of the risk, benefits
and side effects of the procedure
Rationale for the decision
Hyperhidrosis is defined as excessive sweating at rest and during normal
temperature. It affects around 2-3% of the population, with an average age of onset
of 25 years, peaking at 40 years and declining thereafter. Hyperhidrosis can be
classified as generalised, or focal (most commonly axillae, palms and soles).
Generalised hyperhidrosis can be caused by underlying infections, malignancy or
endocrine abnormalities, although most cases of focal hyperhidrosis are idiopathic,
with a possible genetic predisposition. Hyperhidrosis can cause significant physical
and social problems. Patients with excessively sweaty palms may not be able to
handle paper without soaking it, and may experience social stigmatism and
discrimination when shaking hands. People who suffer from axillary hyperhidrosis
often have to change their clothes several times a day due to soaking and staining,
and may be stereotyped as lacking in confidence, leading to social phobia.
Page 1 of 3
There are no standardised diagnostic criteria for focal hyperhidrosis, and the
diagnosis is based on history and physical signs. Gravimetry (milligrams of sweat per
unit time period) can be used to quantify sweat production in secondary care, but is
impractical for routine diagnostic use in primary care. The use of the Hyperhydrosis
disease severity scale is accepted as a means of categorising the clinical severity of
hyperhidrosis in primary care
Hyperhidrosis Disease Severity Scale
My sweating is never noticeable and never interferes with my
daily activities
My sweating is tolerable but sometimes interferes with my daily
activities
My sweating is barely tolerable and frequently interferes with my
daily activities
My sweating is intolerable and always interferes with my daily
activities
Score 1
Score 2
Score 3
Score 4
Topical treatment with aluminium chloride is the appropriate initial treatment in
primary care. Systemic anticholinergics which are unlicensed in this indication may
be used, but due to troublesome side effects they are more usually suited to the
management of generalised hyperhidrosis. A range of other treatment options are
available, for which referral through dermatology clinics is considered the most
appropriate means of access. A treatment algorithm for these is an appendix to this
policy.
Guidance notes on exceptionality
Where the circumstances of treatment for an individual patient do not meet the
criteria described above exceptional funding can be sought. Individual cases will be
reviewed by the appropriate panel of the CCG upon receipt of a completed
application from the patient’s GP, consultant or clinician. Applications cannot be
considered from patients personally.
Date of publication: 16th May 2013
Page 2 of 3
Appendix to commissioning policy for focal hyperhidrosis
Treatment algorithm for focal hyperhidrosis
HDSS score of 2
HDSS score of 3 or 4
Topical aluminium chloride
deodorant 20% (Driclor or
Anhydrol Forte) every night,
reducing as symptoms allow
Topical aluminium chloride deodorant 20% (Driclor or Anhydrol
Forte) every night, reducing as symptoms allow (side effects:
skin irritation common)
(Side effects: skin irritation
common)
Failure to respond after 1 month (or unacceptable side effects)
Palmoplantar hyperhidrosis
Axillary hyperhidrosis
Refer to dermatology department for :
Refer to dermatology department for:
Trial anti-cholinergics (Propantheline or
Oxybutinin). If unsuccessful:
Trial anti-cholinergics (Propantheline or
Oxybutinin). If unsuccessful:
Iontophoresis - 7 treatment sessions over 3
weeks
Trial Iontophoresis where possible. If unsuccessful:
Success: > 50%
reduction in sweat
production or
Failure: < 50%
reduction in sweat
production or
Success: > 50%
reduction in sweat
production
Failure: < 50%
reduction in sweat
production
HSSS ≤ 2
HSSS ≥ 3
HSSS ≤ 2
HSSS ≥ 3
Repeat treatments
every 4 – 12 weeks
or as required
Consider botulinum
toxin injections to
palms / soles under
regional or general
anaesthesia
Repeat botulinum
toxin injections ~
every 6 months
Consider oral anticholinergics
OR
Assessment for botulinum toxin A therapy (50 units
per axilla) if resting sweat production per axilla >
50mg per 5 minutes
OR
Consider local surgical
treatments for axillary
hyperhidrosis
(liposuction / curettage)
Purchase home
iontophoresis
machine
Consider endoscopic thoracic sympathectomy for severe resistant axillary or palmar hyperhidrosis
(long term compensatory hyperhidrosis common side effect)
Page 3 of 3