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Wade R, Rice S, Llewellyn A, et al. Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis. Southampton (UK): NIHR Journals Library; 2017 Dec. (Health Technology Assessment, No. 21.80.)

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Interventions for hyperhidrosis in secondary care: a systematic review and value-of-information analysis.

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Chapter 10Conclusions

The evidence for the effectiveness and safety of second-line treatments for primary hyperhidrosis is limited overall. Most studies were small, rated as being at a high risk of bias and poorly reported. However, there is moderate-quality evidence of a large effect of BTX injections on symptoms of axillary hyperhidrosis compared with placebo. Evidence for other interventions is of low or very low quality. There was insufficient evidence to draw firm conclusions regarding the relative effectiveness and safety of second-line treatments for hyperhidrosis.

The narrative review of quality-of-life measures found that the DLQI, HDSS and HQLQ were used most frequently in hyperhidrosis research. All patients attending the end-of-project workshop preferred the new HidroQoL tool over the DLQI, HDSS or HQLQ and agreed that it captured all hyperhidrosis-related quality-of-life issues.

Although many of the data used to populate the model of axillary hyperhidrosis were derived from small studies at a high risk of bias and poorly reported, when augmented by clinical opinion and other literature the results are quite robust. Only when the effectiveness of iontophoresis sponge was reduced to less than that of placebo did iontophoresis cease to be the optimal first-line treatment choice in a cost-effective sequence at the £20,000 threshold. Only if medication were significantly more effective than BTX, would BTX be displaced from second-line treatment in cost-effective treatment sequences at the £20,000 threshold. VOI analysis showed that, although there is some value in undertaking further research to reduce decision uncertainty, it is unclear if the cost of the research would be offset by the reduction in that uncertainty.

Implications for practice

The findings of the research undertaken suggest that the treatment sequence for axillary hyperhidrosis (iontophoresis, BTX, medication, curettage, ETS) may be cost-effective within the NHS setting. When using medication, propantheline should be used first, before trying more expensive alternatives such as glycopyrrolate.

Implications for research

The VOI analysis showed that, although there is some value in undertaking further research to reduce decision uncertainty, it is unclear if the cost of the research would be offset by the reduction in that uncertainty. The VOI analysis also indicates that further research into the effectiveness of existing medications might be worthwhile, but it is unclear if such trials are of clinical importance. Research that established a robust estimate of the annual incidence of axillary hyperhidrosis in the UK population would reduce the uncertainty in future VOI analyses.

The implications from the systematic review of clinical evidence were as follows.

Botulinum toxin for hyperhidrosis of the axilla

There is sufficient evidence demonstrating the clinical effectiveness of BTX for hyperhidrosis of the axilla; therefore, there is little value in undertaking further studies of BTX compared with placebo for hyperhidrosis of the axilla. Future trials of interventions for hyperhidrosis of the axilla should use BTX as an active comparator.

Iontophoresis for palmar/plantar hyperhidrosis

Iontophoresis studies consistently show that iontophoresis is more effective than placebo/no treatment for hyperhidrosis of the palm; therefore, there is little value in undertaking further studies of iontophoresis compared with placebo/no treatment for hyperhidrosis of the palm. Iontophoresis is currently standard practice for palmar hyperhidrosis in many dermatology units.

Iontophoresis compared with botulinum toxin for palmar hyperhidrosis

A well-conducted, adequately powered, RCT of BTX (with anaesthesia) compared with iontophoresis for palmar hyperhidrosis may be warranted. The new HidroQoL tool appears appropriate for capturing hyperhidrosis-related quality-of-life issues. The cost of BTX plus anaesthesia is considerably higher than the cost iontophoresis; therefore, cost-effectiveness would also need to be assessed.

Microwave, laser, fractionated microneedle radiofrequency and ultrasound

There are ongoing studies of microwave, laser, fractionated microneedle radiofrequency and ultrasound therapies. If the results of this ongoing research are promising, then a trial comparing these new energy-based technologies with BTX for hyperhidrosis of the axilla may be warranted; patients expressed interest in a permanent treatment.

Curettage compared with botulinum toxin for hyperhidrosis of the axilla

In view of the ongoing research into less invasive energy-based technologies (microwave, laser, fractionated microneedle radiofrequency and ultrasound), a trial comparing BTX with curettage for hyperhidrosis of the axilla may not be warranted at this time. When further evidence is available on the newer energy-based technologies, then it will be clearer whether or not further research on curettage is warranted. Patients expressed interest in a permanent treatment, but were concerned about scar tissue resulting from curettage.

Comparison of different oral/topical medications: propantheline bromide, glycopyrrolate, oxybutynin, methantheline bromide and newer medications

There are ongoing/recently completed trials of new oral and topical anticholinergic medication formulations and, therefore, it is unlikely to be worthwhile undertaking further research of the anticholinergic medications currently available. Different medications may work better for some patients than others, therefore it may be difficult to power a study to find any statistically significant differences between treatments.

Copyright © Queen’s Printer and Controller of HMSO 2017. This work was produced by Wade et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK470657

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