Goals of Therapy in Treating Hyperhidrosis

Dee Anna Glaser, MD: I think this is kind of an interesting time to think about how to address some of those gaps. Adelaide, I know you are on the International Hyperhidrosis Society’s board. Is that one of their goals? And what are some of their other goals?

Adelaide Hebert, MD: Absolutely. The International Hyperhidrosis Society provides unbiased education for physicians, patients, and schoolteachers. We have a great program for education for schoolteachers and school nurses. These are amazing resources that can be accessed virtually anywhere. It’s not just in English, either. We’ve actually provided education for colleagues throughout the world in a variety of languages. This is a great strength of our platform. The International Hyperhidrosis Society also is very active in giving lectures. We recently had our interface with the US Food and Drug Administration, to provide increased education for that group of physicians and scientists and help them to understand that this truly is a medical condition, not just a cosmetic concern, and that we really need to expand the frontier of therapeutics so that we can help our patients even more than we’ve been able to do thus far.

Dee Anna Glaser, MD: It is a unique site in the sense that it is geared toward patients and physicians. It’s focused on insurance coverage. Really, it’s kind of that whole well-rounded approach. I guess the real step is, then, not only getting people to understand what it is and who to go to but also, what do we do? How do we treat it? What are the goals of therapy when you sit down with that patient who has severe sweating, where it is really having a big impact on their quality of life? What or how do you start?

Adam Friedman, MD, FAAD: First of all, our armament is there. We have stuff, just not a ton. I think it’s about balancing reducing that sweat to limit impact on quality of life. There’s also a physical component to sweating. Sweat is an irritant, so a lot of patients get irritant dermatitis, or a form of eczema, especially in body folds. There are 2 elements to that. With that in mind, some of the topicals that we have will also do that. They can also be very irritating. So, it’s not just about picking the right therapy, but it’s also about educating people on how to use it correctly. I think there’s a lot of misinformation about how to use something as simple as an antiperspirant—when the right time is to actually use it. In an ideal world, you give a patient something that will reduce their sweating and allow them to feel more comfortable in their own skin, so to speak, and also limit the side effects associated with these treatments. And these are not just physical side effects. These are also financial. So, it’s very patient dependent. It’s very site dependent, especially given that certain therapies can just be used in certain locations—certain device-based therapies. I think it’s very patient oriented. It’s not just about the disease but them, as a person, and what their means are.

Dee Anna Glaser, MD: Yes. Are there any special considerations in the pediatric group that you’re treating?

Adelaide Hebert, MD: Well, I know many patients and parents have concerns about safety, so we try to use medications that are known to be safe in children. The irritation factor, as Adam mentioned, can be a real obstacle when you’re dealing with the pediatric patient. But I try to use the entire spectrum, when appropriate, for pediatric patients. That can range from topical agents to iontophoresis to even 1 of the botulinum toxins, if the patient is willing to undergo that type of therapy. I think children warrant every bit of therapy that we can offer to our adult patients, as long as they’re willing to tolerate it and we can get insurance access for them.

Dee Anna Glaser, MD: Yes. When I see a patient, I try, if possible, to start with something focal. And, as you said, I try to use something that has a very high safety profile and good tolerability. And then I may start to add on as I need to. Maybe I’ll then use a systemic agent. That might have some side effects or interactions with other medications. For me, one of the things is to really try to educate the patient that they’re still going to sweat. We’re going to bring down that sweat, hopefully, and bring down some of the impact on their quality of life, but we cannot make them bone-dry. Normal people sweat. And so, I think that is a really good starting point with a patient—to make sure that we’re all on the same page with the expectations of what we’re going to be able to achieve.

Adam Friedman, MD, FAAD: Something that you said that is very important is that you add on, not replace. I’ve seen a lot of failures where a topical antiperspirant, even a prescription strength, doesn’t work. “Get rid of that. Let’s try something else.” It’s not about replacing. It’s about adding on. In dermatology, we’re really great with synergistic therapies—combination therapies. This is a great example of that. You can’t use one or the other. You want to use multiple therapies, especially if your first-line option doesn’t work.

Dee Anna Glaser, MD: Yes. This is not typically a monotherapy disease. It really usually does require multiple therapies. I think that’s really important to understand.