Treatment pathway for focal hyperhidrosis in Primary Care

History and diagnosis (exclude secondary hyperhidrosis) Refer to secondary care in cases of Offer lifestyle advice: secondary hyperhidrosis of unknown http://cks.nice.org.uk/hyperhidrosis http://www.hyperhidrosisuk.org/self-help.html cause.

Assess site and HDSS score Address cause if known (e.g. hyperthyroidism , menopause, http://www.sweathelp.org/pdf/HDSS.pdf medication, amphetamines)

Primary/focal hyperhidrosis: Antiperspirants: purchase extra strength Successful after 1 month (see criteria antiperspirants; see Hyperhidrosis UK website for below): continue and review regularly. details : https://hyperhidrosisuk.org/treatment -options/self -help/

Patient self-management leaflet: Criteria for successful treatment of

hyperhidrosis: information_leaflet_- _self-management_of_excessive_sweating[1].doc Reduction in HDSS from 3 or 4 to HDSS 1 or 2.

Treatment failure can be defined as no change in HDSS score after 1 month of therapy or lack of tolerability for the treatment. Not successful after 1 month

Successful after 1 month (see criteria Con sider oral anticholinergic * above): continue and review regularly.

NOT successful after total of SIX months of conservative care or treatment limiting side-effects:  HDSS 1 or 2 stop treatment  HDSS 3 or 4 refer to GPwER / secondary care providing a full drug history of antiperspirants and anticholinergics trialled and reasons for failure.

*First-line: Oxybutynin 2.5mg IR (unlicenced indication): start with 2.5mg OD and gradually titrate according to response to a maximum of 5mg QDS. Modified release (MR) tablets for use when immediate release oxybutynin not tolerated (dose as in BNF). Alternative options such as Tolterodine IR or Darifenacin could be offered if oxybutynin effective but not well tolerated (unlicensed indications).

Propantheline bromide is licenced for hyperhidrosis, start with 15mg OD and gradually titrate according to response (see SPC for more details). However it is more expensive option than above, only use if first line options are not tolerated.

Glycopyrronium bromide. Not recommended for prescribing in Primary or Secondary Care. (MOPB 2017) Review patients on glycopyrronium bromide if suitable for switching to oxybutynin.

Please refer also to WECCG website for “Anticholinergic side effects and Prescribing Guidance” .

Based on the East of England Priotities Advisory Committee (PAC) document ‘The Management of Hyperhidrosis’ (2014) West Essex CCG Approved January 2016; Reviewed September 2018; Review Date September 2020