1. Aetna considers treatment of intractable, disabling primary hyperhidrosis with botulinum toxin type A (Botox), botulinum toxin type B (Myobloc) (see CPB 113 - Botulinum Toxin) or iontophoresis (see CPB 229 - Iontophoresis) (electrophoresis, Drionic device) medically necessary when all of the following criteria are met:

   1. Topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; and
   2. Member is unresponsive or unable to tolerate at least one of the following pharmacotherapies prescribed for excessive sweating if sweating is episodic:anti-cholinergics, beta-blockers, or benzodiazapines; and

   3. Significant disruption of professional and/or social life has occurred because of excessive sweating.

2. Aetna considers the following surgical treatments for hyperhidrosis medically necessary for members who meet the above-listed criteria (A through C)  and have failed to adequately respond to treatment with iontophoresis (Note: a trial of botulinum toxin can be substituted for iontophoresis in persons with predominantly axillary hyperhidrosis):

   1. Open thoracic sympathectomy
   2. Thoracoscopic sympathectomy (see CPB 310 - Thoracoscopic Sympathectomy)
   3. Endoscopic thoracic sympathectomy
   4. Video-assisted thoracic sympathectomy (VATS)
   5. Video-assisted endoscopic thoracic ganglionectomy
   6. Endoscopic sympathetic ablation by electrocautery
   7. Chemical thoracic sympathectomy
   8. Lumbar sympathectomy
   9. Tumenescent liposuction for axillary hyperhidrosis

   10. Excision of axillary sweat glands.

3. Aetna considers any of the following treatments for hyperhidrosis experimental and investigational because they have not been proven to be effective for this indication:

   1. Psychotherapy
   2. Hypnosis

   3. Alternative therapy methods including homeopathy, massage, acupuncture and phytotherapeutic drugs.

Sweating is a natural phenomenon necessary for the regulation of an individual's body temperature. Hyperhidrosis, or excessive sweating, is a medical condition that is defined as sweating beyond what is necessary to maintain thermal regulation.

Hyperhidrosis is classified as primary or secondary, depending on its cause or origin. Primary hyperhidrosis, also known as essential or idiopathic hyperhidrosis, is caused by an overactive sympathetic nervous system. It can lead to intractable and profuse sweating in several locations of the body, including palms (hands), axillae (armpits), and planta (feet). Secondary hyperhidrosis is the result of an underlying condition, such as Parkinson's disease, hyperthyroidism, diabetes mellitus, hyperpituitarism, pyrexia, hypoglycemia, or menopause. Secondary hyperhidrosis usually affects the whole body.

Regardless of the type or cause of hyperhidrosis, severe palmar and plantar hyperhidrosis can disrupt professional and social life and may lead to emotional problems. In the case of secondary hyperhidrosis, treatment of the underlying condition should first be attempted. In patients with disabling primary hyperhidrosis, a variety of treatment methods have been used.

The simplest method to control or reduce profuse sweating is the application of topical agents, such as aluminum chloride or other extra-strength chemical antiperspirants. Usually recommended as the first therapeutic measure, topical antiperspirants are effective in cases with light to moderate hyperhidrosis but have to be repeated regularly. Drysol (aluminum chloride hexahydrate) is a prescription topical antiperspirant commonly prescribed for excessive sweating. Drysol is reported to work in 80% of persons who use it for excessive sweating.  Treatment is repeated nightly until sweating is under control.  Thereafter, Drysol is applied once or twice weekly or as needed.

Oral prescription medications may be prescribed for situational or episodic hyperhidrosis, including anticholinergics (e.g., Robinul, Ditropan), beta-blockers (e.g., atenolol, propanolol), and benzodiazapines (e.g., Valium, Ativan). Anticholinergic medications may be effective for alleviating hyperhidrosis (ATTRACT, 2002: Altman and Kihiczak, 2002; GP Notebook, 2003). Anti-cholinergics such as propantheline bromide, glycopyrrolate, oxybutynin, and benztropine are effective because the pre-glandular neurotransmitter for sweat secretion is acetylcholine (although the sympathetic nervous system innervates the eccrine sweat glands). Some anticholinergics are better tolerated than others. Nyamekye (2004) states: "The most effective anticholinergic drug, glycopyrrolate (Robinul and Robinul Forte, Mikart, Inc., Pharmaceutical Manufacturers, Atlanta, GA) has mild side-effects and is generally well tolerated .... Topical glycopyrrolate has also been used in the treatment of localised secondary gustatory sweating." Adverse effects of anti-cholinergics include mydriasis, blurry vision, dry mouth and eyes, difficulty with micturition, and constipation. In addition, there is some evidence that other systemic medications, such as indomethacin and calcium channel blockers, may be beneficial in the treatment of palmoplantar hyperhidrosis (see, e.g., Feder, 1995; Eedy & Corbett, 1978; Tkach, 1982). Anxiolytics, sedatives, or beta-blockers (e.g., propranolol) may be helpful when history indicates that symptoms are precipitated or exacerbated by stress (see, e.g., Tyrer, 1998; Noyes, 1985; Fonte & Stevenson, 1985; GP Notebook, 2003).

Iontophoresis or electrophoresis can be tried if antiperspirants are not effective. Iontophoresis uses electric current to enhance drug penetration through the stratum corneum, the principal barrier to percutaneous absorption. Iontophoresis has been reported to provide temporary relief in mild cases of primary hyperhidrosis of the hands and feet. The procedure has to be repeated regularly, initially in 20-minute sessions several times a week, gradually stretching out the interval between treatments to 1-2 weeks. Treatments must be maintained indefinitely to control the symptoms of mild hyperhidrosis. The results vary: some many find the electric current uncomfortable and the treatments time consuming and not lasting long enough. The Drionic device (General Medical Co., Los Angeles, CA) is an iontophoretic device that can be purchased for home use.

Botulinum toxin type A (Botox) has been found to inhibit the release of acetylcholine not only at the neuromuscular junction, but also in post-ganglionic sympathetic fibers to sweat gland. It is indicated for the treatment of hyperhidrosis of the palms and axillae; intracutaneous injections of Botox have been shown to induce a temporary anhidrosis. Responses have been as long as 1 year, but in most cases the effect begins to weaken in 4 months. Although effective, the clinical usefulness of this treatment is limited by the need for multiple and repetitive relatively painful injections. The reports in clinical trials of increased palmer sweating in patients with axillary hyperhidrosis should also be noted, and it has not been reported in clinical trials whether this subsided as the effects of treatment wore off. In patients with palmer hyperhidrosis, another consideration might be the long-term effects on muscle tone, as weakness has been reported in the small muscles of the hands with botulinum toxin treatment (Bandolier, 2002).

In severe cases of intractable, disabling primary hyperhidrosis, surgical intervention has been utilized. The principle of sympathectomy is to interrupt the nerve tracks and nodes that transmit the signals to the sweat glands. This can basically be achieved for all locations in the body, but only the nerve nodes responsible for the sweat glands of the palms and the face are accessible without the need for a major surgical procedure. With the advent of minimally invasive endoscopic sympathectomy, open surgical sympathectomy or upper thoracic ganglionectomy at T2 -T4 has come into disfavor because of the magnitude of the procedure, the long periods of hospitalization and recovery, and the complication rate. Whether performed open or endoscopically, the most common side effect of surgery is compensatory hyperhidrosis characterized by a moderate increase in sweating in other parts of the body. A rare side effect is "gustatory sweating", a condition that leads to the sensation of sweating when eating. Another possible complication is Horner's syndrome resulting in a slightly smaller pupil and a slightly drooping eyelid on the affected side. The new technique of clipping the sympathetic nerve is generally viewed as the best option currently available because it is reversible by removing the nerve clip in patients with severe and unmanageable compensatory sweating. Lumbar sympathectomy, an open abdominal procedure, can cure isolated plantar hyperhidrosis; however, it is not usually employed because of the risk of sexual dysfunction.

Dressler and colleagues (2002) reported on a self-controlled study comparing the effectiveness of Botox and botulinum toxin type B in persons with bilateral axillary hyperhidrosis.  A total of 19 subjects with axillary hyperhidrosis received botulinum toxin type B in one axilla and Botox in the other axilla.  These investigators reported that all subjects except one reported excellent improvement in hyperhidrosis in both axillae, and that none of the subjects had residual hyperhidrosis on clinical examination.  The duration of effect was not statistically significantly different between Botox and botulinum toxin type B.

In a randomized controlled clinical trial, Baumann and Halem (2004) reported on the use of botulinum toxin B in the treatment of patients with palmar hyperhidrosis.  A total of 20 subjects with hyperhidrosis were randomly assigned to injection with botulinum toxin type B (n = 15) or placebo (n = 5).  These researchers reported a significant difference in treatment response (as determined by participant assessment) between the subjects injected with botulinum toxin B and placebo.  The duration of cessation of palmar sweating ranged from 2.3 months to 4.9 months, with a mean duration of 3.8 months.  The authors stated, however, that 18 of 20 participants reported dry mouth/throat, 60 % reported indigestion/heartburn, 60 % reported muscle weakness, and 50 % reported decreased grip strength.  These investigators concluded that botulinum toxin B was safe and effective in treating bilateral palmar hyperhidrosis.  However, the side effect profile was substantial.

In a review on the use of botulinum toxins for the treatment of patients with hyperhidrosis and gustatory sweating syndrome, Glaser (2006) stated that both diseases respond very well to botulinum toxin therapy.

Surgical removal of sweat glands has been shown to be only effective in the treatment of axillary hyperhidrosis, and may leave significant scarring. For a person suffering from primary hyperhidrosis, this approach is usually only a partial solution to the problem, especially since the most annoying areas usually are the hands.

Poor results have been reported with the use of psychotherapy and hypnosis. Psychological problems are in most cases a consequence of hyperhidrosis, not the cause. Hence, psychiatric or psychopharmacologic therapy cannot cure this disorder; at most it may help the patient to accept living with the problem.

Alternative medicine interventions, including homeopathy, massage, acupuncture and phytotherapeutic drugs, have not been proven effective.