103
CLINICAL REPORT
Hyperhidrosis Substantially Reduces Quality of Life in Children:
A Retrospective Study Describing Symptoms, Consequences and
Treatment with Botulinum Toxin*
Sandra ERIKSSON MIRKOVIC 1 , Alma RYSTEDT 1 , Mie BALLING 1 and Carl SWARTLING 1,2
Hidrosis Clinic, Stockholm, and 2 Department of Medical Sciences, Dermatology and Venereology, Uppsala University, Sweden
1
Studies on children with hyperhidrosis are sparse. This
retrospective study presents clinical data and quality
of life, along with treatment effect and safety of bo-
tulinum toxin (BTX). Case reports from 366 children
were included to capture the medical history of hy-
perhidrosis. The total median score of the Dermato-
logy Life Quality Index before treatment was 11 for
children aged 16–17 years and 12 for children younger
than 16 years. The children described physical, psy-
chosocial and consequence-related symptoms. More
than 70% had multifocal hyperhidrosis. BTX-A and/or
BTX-B were given to 323 children, 193 of whom recei-
ved repeated treatments. The highest score in a 5-gra-
de scale concerning treatment effect was reported by
176/193 children, i.e. their “sweating disappeared
completely”. No severe adverse events occurred. Focal
and multifocal hyperhidrosis in children reduces qua-
lity of life considerably. Treatment with BTX-A and/or
BTX-B has been performed with success.
Key words: hyperhidrosis; children; botulinum toxin; botulinum
toxin type A; botulinum toxin type B; quality of life.
Accepted Jul 31, 2017; Epub ahead of print Aug 1, 2017
Acta Derm Venereol 2018; 98: 103–107.
Corr: Carl Swartling, Hidrosis Clinic, Warfvinges väg 35, SE-112 51
Stockholm, Sweden. E-mail: [email protected]
P
rimary focal and multifocal hyperhidrosis is a pa-
ediatric inherited disease with diagnostic criteria (1).
Hyperhidrosis localized on the palms, feet and axillae
is thought to be due to low thresholds to arousal in the
limbic system and frontal cortex. Hyperhidrosis in the
craniofacial area, trunk, inguinal region and limbs may
result from low thresholds to heat/effort in the “thermo-
stat” hypothalamus (2).
The prevalence of the disease has been estimated as
2.8% in a large American epidemiological study (3).
Although the prognosis is unknown, our experience is
that the condition is chronic in most cases, but that the
phenotype may change over time. For example, palmo-
plantar hyperhidrosis in youth can change to excessive
sweating from head-trunk in middle age.
*This study was published as an abstract and a poster at the international conference TOXINS
2017: Basic Science and Clinical Aspects of Botulinum and Other Neurotoxins in Madrid, Spain
on January 18–21, 2017.
Primary hyperhidrosis is a stigmatizing disease with
physical, psychosocial and consequence-related symp-
toms. Quality of life (QoL), measured with the Derma-
tology Life Quality Index (DLQI), is severely affected
in adults with hyperhidrosis, with results comparable to
the most severely affected patients with psoriasis and
isotretinoin-treated acne (2). Many elderly people with
hyperhidrosis remember their childhood and youth as a
troublesome period with respect to the disease, but there
is little reference in the literature to QoL in children with
hyperhidrosis (4, 5).
First-line treatment of focal hyperhidrosis of the palms,
feet and axillae is with an antiperspirant containing
aluminium chloride. Second-line treatment is multiple
local injections of botulinum toxin type A (BTX-A) and
botulinum toxin type B (BTX-B) over the areas affected
by excessive sweating (2). Although primary focal hy-
perhidrosis is a paediatric disease, nearly all studies on
BTX in hyperhidrosis have been performed on adults.
However, BTX can be used in cerebral palsy (CP) from
the age of 2 years, and primary hyperhidrosis in the
axillae, cervical dystonia and blepharospasm/hemifa-
cial spasm can be treated from the age of 12 years with
Botox ® (Allergan, Irvine, CA, USA).
Adverse events due to the use of BTX in the treatment
of hyperhidrosis are few, local and temporary. Muscle
weakness, i.e. impaired grip function or stiff forehead,
is reported in the treatment of palms or head. Another
reported adverse event is compensatory sweating in
non-treated areas. By contrast, less sweating from non-
injected areas has been reported.
BTX-B is a novel treatment for hyperhidrosis and has
been used in the forehead/central face and over the thenar
eminence to avoid muscle weakness (6, 7).
Other treatment options for focal hyperhidrosis are
miraDry ® (Miramar Labs, Sunnyvale, CA, USA), ionto
phoresis, anticholinergics, and surgery. According to gui-
delines from The National Board of Health and Welfare
in Sweden, endoscopic thoracic sympathectomy (ETS)
is the final optio