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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