don’t sweat it: treatments for hyperhidrosis...don’t sweat it: treatments for hyperhidrosis...
TRANSCRIPT
Don’tsweatit:treatmentsforhyperhidrosis
ZakiyaP.Rice,MD,FAAD,FAAPAssistantProfessorofDermatologyandPediatrics
DirectorDermatologyClinicalTrialsUnitEmoryUniversitySchoolofMedicine
April1,2017
ExternalIndustryRelaMonships*
CompanyName Role
Equity,stock,orop/onsinbiomedicalindustrycompaniesorpublishers
None
BoardofDirectorsorofficer
CoquilleEconomicDevelopmentCorp(CEDCO)Mith-ih-kwuhEconomicDevelopmentCorp(MEDCO)
WilliamS.RiceMPA,Husband,BoardMember
Royal/esfromEmoryorfromexternalen/ty
None
IndustryfundstoEmoryformyresearch
Sanofi-Genzyme/RegeneronPharmaceu/cals,Inc.(AD)AnacorPharmaceu/cals,Inc.(AD)CelgenePharmaceu/cals,Inc.(AD/PsO)Menlo(CP)Incyte(Vi/ligo)Galderma(PsO)Merck&Co.(Neurology)AbbVie(Neurology)Janssen(Neurology)
PrincipalInves/gator(PI)PIPI/Co-Inves/gator(CI)PI(par/alsalarysupport,PSS)CI(PSS)CI(PSS)CI(PSS)CI(PSS)CI(PSS)
Other PierreFabreGlobalPointeHealthprac/ceStatelineFilmsGeorgiaPhysiciansAssistantsSocietyCNNInterna/onalHyperhidrosisSociety
HonorariumHonorariumHonorariumHonorariumHonorariumHonorariumHonorarium/Dis/nguishedFaculty
ObjecMves
1) Reviewthequalityoflife(QoL)impactofhyperhidrosis(HH)
2) ReviewtheknownpathophysiologyofHH3) ReviewthetreatmentopMonsforHH
Outline
DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH
Outline
DefiningHH(reviewingclassifica/on)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH
ID:A21yearoldfemaleHPI:8yearhistoryofexcesssweaMngofherpalmsbilaterallyMEDS:NONEROS:NegaMve
www.miamidermlaser.com.AccessedSept1,2015.
QuesMon#1Herdiagnosisismostconsistentwith:A) GeneralizedHHB) RegionalHHC) PrimaryfocalHHD) AquagenicpalmarkeratodermaE) Noneoftheabove(thisisdegreeofsweaMng
isnormal)
WhatisHyperhidrosis?
Swea%ngthatismorethanrequiredtomaintainnormalthermalregula%on
Hornbergeretal.JAAD.2004.
www.hyperhidrosisuk.org.AccessedSept1,2015.
DiagnosisofPrimaryFocalHyperhidrosis
• Focal,visible,excessivesweaMngofatleast6monthsduraMon,withoutapparentcause,withatleast2ofthefollowingcharacterisMcs:– BilateralandrelaMvelysymmetric– ImpairsdailyacMviMes– Frequencyofatleastoneepisodeperweek– Ageofonsetlessthan25years– PosiMvefamilyhistory– CessaMonoffocalsweaMngduringsleep
Hornbergeretal.JAAD.2004.
Primaryvs.Regionalvs.Generalized
Type Clinicalpresenta/on Causes
PrimaryFocalHH Focal,bilateral,symmetricsweaMng Idiopathic
SecondaryFocalHH FocalsweaMng,asymmetrical Neurologicaldisorders(i.e.Freysyndrome),NeoplasmsTrauma
GeneralizedHH GeneralizedsweaMng Endocrinedisorders(i.e.Pheochromocytoma,thyrotoxicosisetc.)DrugsTumorsFebrilediseasesSpinalcordsinjuryCutaneousdiseases
Glaseretal.Cu6s.2007.
Aquagenicpalmarkeratoderma
Outline
DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH
www.cancer.penmedicine.org.AccessedSept1,2015.
QuesMon#2WhatistheprevalenceofHH?
A) 0.03%B) 1%C) 2.8%D) 10%E) 28%
PrevalenceofHH
• 2.8%oftheUnitedStatesPopulaMon(7.8million)– Comparabletopsoriasis– UnderesMmate(widelyundiagnosedanduntreated)
Strueonetal.JAAD.2004.
PrevalenceofHH(Cont.)
• 2/3rdofHHpaMentsdonotconsulttheirphysician
• HHpaMentswaitforameanof8.9yearsbeforeseekingtreatment– NotknowingtreatmentopMons– NotabletofindaproviderfamiliarwithHHtreatmentopMons
– NotknowinginsurancecoverageopMons– Embarrassment
Wallingetal.JAAD.2009.
Outline
DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH
“Neverletthemseeyousweat!”
www.huffingtonpost.com.AccessedSept.1,2015.
www.huffingtonpost.com.AccessedSept.1,2015.
www.telegraph.uk.com.AccessedSept.1,2015.
www.businessinsider.com.AccessedFebruary26,2017.
QoLinHH
“Iusuallywearblackandtrynottolimmyarms.”“Myfeetarealwaysinfectedwithfungusandaresore.”“Mypenslipsoutofmyhandsandmypaperisalwayswet.”“Iamnotabletoplaybaseball(myfavoritesport)becausethebatfliesoutofmyhands”“Ihavenottakenajoboutsidemyhouse.”“IwoulddoanythingtoimprovemysweaMng!”
www.Mmeforhealthcare.org.AccessedSept1,2015.
www.chir.it.AccessedSept.1,2015.
www.shoesqueta.atspace.co.uk.AccessedSept.!,2015.
QoLinHH(Cont.)Condi/on DermatologyQualityLifeIndex
Hyperhidrosis 10.1
Severeacne 9.2
Pruritus 9.2
Psoriasis 8.9
AtopicDermaMMs 7.3
Hailey-Hailey 6.1
Darier’sDisease 5.9
ViMligo 4.8
Swartlingetal.EJNeurol.2001.
Outline
DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH
QuesMon#3
TheunderlyingpathophysiologyofHHisduetoan:
A) IncreaseddensityofeccrineglandsB) IncreasedsizeofeccrineglandsC) IncreasedacMvityoftheeccrineglandsD) Increasedreleaseoftheacetycholine(ACh)E) IncreaseduptakeoftheACh
PathophysiologyofHH
• Poorlyunderstood• Normaldensityandsizeofeccrineglands• Overs/mula/onoftheeccrineglandsinnervatedbypostganglioniccholinergicsympathe/cfibers
Satoetal.JAAD.1989.Loweetal.BJD.2004.
• CartoonofpostsynapMcclem
Eccrinecell
www.gi.jhsps.org.AccessedSept1.2015.
PathophysiologyofHH(Cont.)
• ProbablygeneMc– Geneunknown– AD,variablepenetrance– 30-50%haveaknownfamilyhistoryofHH
Haideretal.CMA.2005.
Outline
DefiningHH(reviewingclassificaMon)EpidemiologyofHHQoLinHHPathophysiologyofHHTreatmentofHH
QuesMon#4
TopicalanM-perspirantsmechanismofacMon(MOA)is:
A) PhysicalblockadeofeccrineductsB) DecreasedreleaseofAChC) IncreaseddestrucMonofAChD) DecreaseduptakeofAChE) Thermolysisofeccrinecells
TreatmentofHHNon-invasive Minimally
invasiveModeratelyinvasive
Surgical
TopicalmedicaMonsSystemicmedicaMons
IontophoresisBotulinumtoxininjecMons
MicrowaveThermolysis
ExcisionLiposucMonSympathectomy
M*PO
TreatmentofHH
• Topical– Aluminum/Zirconiumsalts– UsedalllocaMons,mosteffec/veaxillae
www.hyperhidrosisnetwork.com.AccessedSept1,2015.
QuesMon#5
ThemostcommonsideeffectameruseoftopicalanM-perspirantis:
A) IrritaMonB) DryeyesandmouthC) MuscleparalysisD) DysesthesiaE) Compensatoryhyperhidrosis
TreatmentofHH
M+nCl+nmolesBaseàM(base)3ppt+nHClBasemaybeOHfromwater,lactate,orproteinBestappliedtodryareaintheeveningbeforebed.
QuesMon#6
Glycopyrrolate’sMOA:
A) PhysicalblockadeofeccrineductsB) DecreasedreleaseofAChC) IncreaseddestrucMonofAChD) DecreaseduptakeofAChE) Thermolysisofeccrinecells
TreatmentofHH
• SystemicmedicaMons– An/cholinergics(glycopyrrolate>>oxybutynin)– Beta-blockers– CalciumChannelBlockers– Alphaandrenergics– Benzodiazepines
• CartoonofpostsynapMcclem
Eccrinecell
www.gi.jhsps.org.AccessedSept1.2015.
TreatmentofHH
• SystemicanMcholinergicsarebesttouse:– GeneralizedHH– MulMpleareasofinvolvement– Largeareasofinvolvement– Craniofacial– MulM-therapyapproachwithotheragents
QuesMon#7
ThemostcommonsideeffectamertheuseofasystemicanMcholinergicis:
A) IrritaMonB) DryeyesandmouthC) MuscleparalysisD) DysesthesiaE) Compensatoryhyperhidrosis
TreatmentofHH
• AnMcholinergicsideeffects– Ocular:Dryeyes,mydriasis,cycloplegia– GI:Drymouth,reducedgastricsecreMons– RESP:BronchodilaMon,reducedsecreMons– GU:UrinaryretenMon(relaxessmoothmuscleuretersabladderwall)
– CARD:Cardiacarrythmias(bradycardiaatlowdosesandtachycardiaathighdoses)
Palleretal.JAAD.2012.
TreatmentofHH
• AnMcholinergicContraindicaMons– Absolute• Glaucoma• Impairedgastricemptying• UrinaryretenMon
TreatmentofHH
• AnMcholinergiccauMon– OutdooroccupaMon/athlete– PediatricpaMents– Age>65yearsold• SystemicanMcholinergicsassociatedwithdemenMa
Grayetal.JAMAInternalMed.2015.
QuesMon#8TheMOA
ofiontophoresisis:A) PhysicalblockadeofeccrineductsB) DecreasedreleaseofAChC) IncreaseddestrucMonofAChD) DecreaseduptakeofAChE) Thermolysisofeccrinecells
TreatmentofHH
• Iontophoresis– Passingofionizedsubstancethroughintactskinbyuseofelectricalcurrent
– Forprimaryfocalpalmar/plantarHH• Oneofthebestop/ons
www.rafisher.org.AccessedSept.1,2015.
TreatmentofHH
• MOAofIontophoresis– BlockageofsweatglandsfromiondeposiMon– BlockingofsympatheMcnervetransmission– DecreaseinpHduetoaccumulaMonofhydrogenions
Hilletal.Cu6s.1981.Anlikeretal.CurProbDermatol.2002.Wangetal.Br.J.Dermatol.1994.
QuesMon#9
Themostcommonsideeffectamertheuseifiontophoresisis:
A) IrritaMonB) DryeyesandmouthC) MuscleparalysisD) DysesthesiaE) Compensatoryhyperhidrosis
TreatmentofHH
• AdverseeventsfromIontophoresis– SMnging/Mngling/“pinsandneedles”duringtreatment
– Erythemaalongthewaterlineofthehand– DermaMMs,vesiculaMon
QuesMon#10TheMOA
ofbotulinumtoxin(BTX)is:A) PhysicalblockadeofeccrineductsB) DecreasedreleaseofAChC) IncreaseddestrucMonofAChD) DecreaseduptakeofAChE) Thermolysisofeccrinecells
EccrinecellEccrinecell
www.gi.jhsps.org.AccessedSept1.2015.
www.microbewiki.kenyon.AccessedSept1.2015.
TreatmentofHH
• BTXA– OnabotunilumtoxinA(Botox®)• FDAapprovedJuly19,2004forsevereprimaryaxillaryHH
– AbobotulinumtoxinA(Dysport®)• NotFDAapprovedforHH
– IncobotulinumtoxinA(Xeomin®)• NotFDAapprovedforHH• Maybestoredatroomtemperature
Loweetal.JAAD.2007
TreatmentofHH
• InjecMonsofBTX– Officeprocedure– PaingaMngtechniques– Craniofacial,axillary,palmar,infra-mammary,groin,plantar
– Q4-6months
TreatmentofHH
www.emedicine.medscape.org.AccessedSept1.2015.
• 100unitsofBotox®• Dilute4mlsterileNS• 2.5unitsper0.1ml
• 30gauge,1mlsyringe• 1.5-2cmapart• 2.5unitstoeachsite
www.emedicine.medscape.org.AccessedSept1.2015.
Videos
hep://www.sweathelp.org/educaMon-and-resources/online-learning.html
QuesMon#11
AworrisomesideeffectamertheuseofBTXforpalmarHHis:
A) IrritaMonB) DryeyesandmouthC) MuscleparalysisD) DysesthesiaE) Compensatoryhyperhidrosis
TreatmentofHH
• BTXsideeffects– InjecMonsitepain– InjecMonsitebleeding– CompensatoryHH– Muscleweakness(craniofacialandpalmar)
QuesMon#12TheMOA
ofmiraDryis:A) PhysicalblockadeofeccrineductsB) DecreasedreleaseofAChC) IncreaseddestrucMonofAChD) DecreaseduptakeofAChE) Thermolysisofeccrinecells
TreatmentofHH
• miraDrySystem– ManufacturedbyMiramar
• AxillaryHH(andhairremoval)• FDAapprovedJanuary2011• Usesmicrowaveenergy(580MHz)resulMnginthethermolysisofeccrineglands
www.westcoderm.com.AccessedSept1.2015.
TreatmentofHH
• miraDrysideeffects– Dysethesia(transientalteredsensaMonintreatmentarm)
– Localswelling– Compensatoryhyperhidrosis(rare)– $3K
Glaseretal.DermSurg.2012.
TreatmentHH
• AddiMonaltopicals– Astringents(formaldehyde,gluteraldehyde,tannicacid,aceMcacid)
– Glycopyrrolate(wipesandgel)*– Oxybutynin– Botulinumtoxins
*AvailableCanadaBergstresseretal.IntlJDermatol.2002www.clinicaltrials.gov
Inves/ga/onalAn/cholinergicTopicalGelMayBeSafe,Effec/veForTreatmentOfAxillary
Hyperhidrosis,StudySuggests
• Medscape(3/9,Tucker)reportsthatresearchpresentedattheAmericanAcademyofDermatologymeeMngsuggested“aninvesMgaMonalanMcholinergictopicalgelissafeandeffecMveforthetreatmentofaxillaryhyperhidrosis.”Thegel,Sofpironiumbromide(BBI-4000),“isaspeciallyformulated‘som’topicalanMcholinergicdesignedtoblocksweatproducMon,anditsrapidmetabolicdeacMvaMonandexcreMonreducestheadverseeffectsassociatedwithanMcholinergicagents.”
ObjecMves
1) Reviewthequalityoflifeimpactofhyperhidrosis(HH)
2) ReviewtheknownpathophysiologyofHH3) ReviewthetreatmentopMonsforHH
PaMentswith
hyperhidrosisareaJOYtocarefor!
hep://www.sweathelp.org/
DiagnosisandtreatmentalgorithmsInformedconsentsVideosBrochuresandpostersClinicalresearchposMngsCPTandICD-10codes(insuranceleeers)LiteraturereferencesAndMUCHMORE…
*Ms.LisaPiere|
QuesMons:[email protected]
TreatmentofHH• Glycopyrrolate(PO)– Adults
• 1and2mgtablets• Start1mgPOBID• Increase1mgevery2weeks,dependingonclinicalsideeffects
• Max8mg/day– Children
• Oralsuspension0.5mg/mL• Start0.02mg/kgPOTID• Increase0.02mg/kgevery1-4weeks,dependingonclinicalsideeffects
• Max3mg/day
BillingandCoding• E&M99212-99213• ICD-10PrimaryFocalHyperhidrosis• L74.512axilla• L74.513palms• L74.514soles• R61Craniofacial• CPT
– 97033,iontophoresis,each15min• Typicallybillfor2-4units,dependingonhowmanyareasaretreated
– 64650chemodenervaMonofeccrineglands,axillae– 64653chemodenervaMonofeccrineglands,otherareas(i.e.scalp,
face,neck),– 64999unlistedprocedure,nervoussystem(i.e.handsandfeet)
• J0585,perunitofonabotulinumtoxinA
HDSSHowwouldyourateyourHH Score
SweaMngnoMceable,neverinterferes 1
SweaMngtolerable,someMmesinterferes 2
SweaMngbarelytolerable,frequentlyinterferes 3
SweaMngintolerable,alwaysinterferes 4