There are several treatment options available to patients suffering from facial hyperhidrosis. Dr Sandeep Cliff discusses these options and explains his preferred techniques
Defining hyperhidrosis can be tricky. I don’t tend to strictly adhere to the literal definition and define sufferers as anyone who gets significant sweating to the point where it affects their quality of life. Typically, patients do not complain of excess sweating at night—a useful pointer that there is unlikely to be a secondary cause. It is, however, important to take a full medical history from patients to exclude a secondary cause such as medication and anxiety disorders.
Around 10% of patients who come to me with excessive sweating have hyperhidrosis of the face. This can have a significant impact on their life. People with hyperhidrosis sweat spontaneously—it is the unpredictability of the sweating that causes patients the most distress.
There are four main types of hyperhidrosis, but the most common type I see is sweating of the forehead, which is diffusely present.
Of the patients I’ve seen, one example is a nurse who was transferred from one department to another because she was dripping all over her patients.
Or a shy, reticent teenager who, after having had treatment, became a spokesman for the Hyperhidrosis Society. Treating patients clearly has a positive impact on their quality of life.
When I see a patient I will write down whether I perceive their sweating to be mild or severe. This severity scale would be my interpretation—I’ll then ask them where they fit into that category and we often correlate on the same part of the scale. It’s very useful for me as a guide to how they respond.
Insurance companies will recognise treatment for hyperhidrosis of the face, provided you use this hyperhidrosis severity scale. It’s worth remembering this when supplying information and discussing the case with insurance companies in order to secure authorisation.
Iontophoresis is an electrical current that passes through the skin and blocks the sweat glands very effectively. However, although it’s an effective treatment, it’s very difficult to get masks that stay on the face and produce the effect you want.
Patients find it very uncomfortable because of the vibratory sensation as the electric current goes through the skin. It’s not as effective for the face as it is for the palms and the soles.
I use a lot of propantheline bromide, which is a very effective way of treating hyperhidrosis. It’s given in a dose of 15mg and you can increase the dose up to 60mg.
It’s very fast-acting, so many patients will take the drug two days before they have a big presentation or event in which they’re worried about sweating. They may take it for that event and then only take it when and if they need to, which is a reasonable way to manage the problem.
Many patients in studies published since 2002 have taken the drug and found it to be very effective. However, around a quarter of patients have to stop because of adverse events.
The majority of patients get a good response to all anticholinergics but it is clearly not the solution for some patients due to side effects and the unpredictable nature of the drug
There is a cream called glycopyrrolate, which is an anticholinergic. Another potential problem is that people put the cream on the face and then they start sweating on the neck—compensatory hyperhidrosis. For that reason I don’t tend to use it, but you can get it on the market.
Botulinum toxin is my main treatment for patients who’ve failed the other conventional treatments.
The sweat glands sit in the mid-dermis—there’s the top layer of the skin, the epidermis, the dermis, the fat layer and the muscle, deep down. In the forehead, these are the eccrine sweat glands and they sit 1mm into the skin, so they’re very superficially placed.
The muscle contracts the sweat gland and pushes the sweat out through the duct. Therefore, if you think about the principle of how toxins work, it’s meant to inhibit the muscle contraction by inhibiting acetylcholine release.
A study with 12 patients was originally published in 2000, showing that an average dose of 60 units of botulinum toxin used in the forehead had very effective efficacy, lasting up to 27 months. I’ve never been able to replicate the duration of the effect in clinical practice.Other studies follow on, showing that botulinum toxin is an effective and safe treatment. There’s a good satisfaction score.
More recent studies have also shown that by using 50 units of botulinum toxin (a significantly smaller dose than the original studies), you get no major side-effects. That’s very reassuring for our patients and for us.
They used four units of botulinum toxin injected over every 1cm, so 100 units used on the entire forehead. People who practise aesthetic dermatology know that with 100 units in the forehead, the patient won’t be able to move their entire forehead. So why are we using such a high dose for patients with hyperhidrosis?
The data, which was published in numerous journals in 2002, used 100 units—one vial in the forehead—which is no bigger than six or seven postage stamps.
If you inject four units, 25 injections across the forehead, avoiding 1cm above the eyebrow to avoid brow ptosis, you get a therapeutic benefit. I treated patients four years ago using exactly that protocol.
However, patients were getting significant paralysis of their forehead muscles, which they found unacceptable.
They got a very satisfying response to their sweating, but they were not happy with the fact they couldn’t move their forehead at all. They got the frozen effect. So I moved on to using a technique of injecting the hairline only.
If you inject the hairline, with around seven units per injection, you’ll find that there is a diffusion effect. You get reduced sweating, and a significant therapeutic benefit without causing the frontal paralysis that we were seeing.
I’ve performed this in over 100 patients. Never once have I had a problem with brow ptosis or any other complication related to it.
Another study compared two toxin products—Botox and Azzalure. They showed that if you use a ratio of roughly one to three, you get the same therapeutic benefits. So if you’re using Azzalure, 10 Spey units is equivalent to one injection point.
The studies show that you get an area of anhidrosis, very effectively showing a reduction in sweating in both the Botox and the Azzalure group of patients.
However, the Azzalure patients had a greater area of diffusion, suggesting it may have a greater risk of side effects but this has not been borne in clinical studies or in my practice.
What about other areas of sweating? It’s a big problem for some of our patients. We see patients who have complained of sweating on the upper lip and sweating on the cheek.
We don’t try to inject four units, 1cm apart into the cheek as it causes problems with the zygomaticus major and minor. I use a so-called micro-injection technique. I use 50 units of Vistabel, diluted conventionally with 1.25ml of normal saline. Bacteriostatic doesn’t make any difference in terms of pain because they are superficial injections. I then dilute it tenfold—so I make up 0.1ml and dilute it to 1ml. Every 0.1ml is therefore 0.4 of a unit.
I dilute it down, and with one syringe I inject with multiple injections. With this technique, you get no problems with muscle paralysis from a functional perspective, but you get a significant reduction in their sweating. I find this to be very effective in therapeutic practice.
My patients are very satisfied but the longevity in my experience lasts no more than three months. So I frequently tell these patients that they will need around four treatments per year.
The upper lip can also be a big problem for patients. When we did the starch iodine test on these patients, we found the principle problem with sweating was just below the nasal sill.
So that’s where we want to direct our injection technique. This avoids the orbicularis oris and turns the sweating off very effectively. However, it only lasts one to two months and it is painful for patients and sometimes needs a local anaesthetic.
I would say, of the patients who present to me with hyperhidrosis, about 15–20% will have hyperhidrosis of the face, which is a major problem for them. They’re not particularly keen on systemic treatment because of the associated side effects that have been related to it.
Patients prefer local treatment and botulinum toxin is very therapeutically effective with minimum downtime. However, I keep my doses relatively low, which has a good response. Treatment results in a very satisfied group of patients with few side effects. Temporary muscle weakness has been reported, but I’ve never seen it in the patients I’ve treated.
Dr Sandeep Cliff is a consultant dermatologist, dermatological surgeon, and the lead consultant for Cliff Dermatology Ltd with an aesthetic practice in Surrey. W: cliff-dermatologist.co.uk