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Hyperhidrosis GM Ref: GM016 Version: 3.2 (25 January 2019)

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Hyperhidrosis GM Ref: GM016 Version: 3.2 (25 January 2019) Greater Manchester EUR Policy Statement on: Hyperhidrosis GM Ref: GM016 Version: 3.2 (25 January 2019) Commissioning Statement Hyperhidrosis Policy Treatment/procedures undertaken as part of an externally funded trial or as a part of Exclusions locally agreed contracts / or pathways of care are excluded from this policy, i.e. locally (Alternative agreed pathways take precedent over this policy (the EUR Team should be informed commissioning of any local pathway for this exclusion to take effect). arrangements apply) Policy Hyperhidrosis is a medical condition in which a person sweats excessively and Inclusion unpredictably. People with hyperhidrosis may sweat even when the temperature is Criteria cool or when they are at rest. Prior to Referral This policy applies to primary focal (idiopathic) hyperhidrosis and in some cases where the hyperhidrosis is secondary to an underlying cause, provided all steps have been taken to remove or ameliorate the cause and the hyperhidrosis persists: • Investigate and treat any underlying cause of the hyperhidrosis (see Appendix 2 for a list of potential underlying conditions). • Provide advice on lifestyle modifications made (see list in Appendix 2). • Advise the patient to use (via over the counter purchase) topical aluminium salt + 1% hydrocortisone cream, if necessary. • If topical treatments do not work after 1 month consider an oral anticholinergic (as advised by NICE ES10 Hyperhidrosis: oxybutynin1). • If facilities are available, consider tap water iontophoresis. Referral Axillary Hyperhidrosis • Iontophoresis: the initial schedule of treatment is commissioned for delivery in secondary care - if successful the patient is expected to purchase their own machine for home usage. • If iontophoresis is not successful then the use of Botox, in line with GMMMG guidance, is commissioned. • Where available local surgical management may be considered where none of the above work (laser sweat ablation or retro dermal curettage). Palmar / Planter Hyperhidrosis • Iontophoresis: the initial schedule of treatment is commissioned for delivery in secondary care - if successful the patient is expected to purchase their own machine for home usage. • If iontophoresis is not successful then consider the use of anticholinergics not tried in primary care. • In exceptional cases consider Botox, in line with GMMMG guidance (note the significant risk of complications associated with this). 1 Oxybutynin immediate release (IR, off-label) should be prescribed in preference to glycopyrronium bromide (unlicensed) or propantheline bromide (less effective). The level of evidence for oxybutynin IR and glycopyrronium bromide are of similar strength (weak) – please check relevant GMMMG guidance for up to date information. GM Hyperhidrosis Policy v3.2 FINAL Page 2 of 17 Cranio – Facial Hyperhidrosis • Consider the use of anticholinergics not tried in primary care. • Consider Botox, in line with GMMMG guidance. NOTE: Thoracic sympathectomy carries risks and is NOT commissioned due to weak evidence of success and the high risk of morbidity associated with the procedure. Funding Mechanism Monitored approval: Referrals may be made in line with the criteria without seeking funding. NOTE: May be the subject of contract challenges and/or audit of cases against commissioned criteria. NOTE: Ensure the referral letter / form contains all the management options tried to date, with the outcome for each PLUS comments on all investigations undertaken to rule out an underlying cause for the hyperhidrosis. If the patient does not meet the criteria: an individual funding request can be made if there is a good case for clinical exceptionality provided all conservative treatments have been exhausted. Requests must be submitted with all relevant supporting evidence. Clinical Clinicians can submit an Individual Funding Request (IFR) outside of this guidance if Exceptionality they feel there is a good case for exceptionality. Exceptionality means ‘a person to which the general rule is not applicable’. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: • Significantly different to the general population of patients with the condition in question. and as a result of that difference • They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. Fitness for NOTE: All patients should be assessed as fit for surgery before going ahead with Surgery treatment, even though funding has been approved. Best Practice All providers are expected to follow best practice guidelines (where available) in the Guidelines management of these conditions. GM Hyperhidrosis Policy v3.2 FINAL Page 3 of 17 Contents Commissioning Statement ........................................................................................................................ 2 Policy Statement ...................................................................................................................................... 5 Equality & Equity Statement ..................................................................................................................... 5 Governance Arrangements ....................................................................................................................... 5 Aims and Objectives ................................................................................................................................. 5 Rationale behind the policy statement ...................................................................................................... 6 Treatment / Procedure .............................................................................................................................. 6 Epidemiology and Need ........................................................................................................................... 6 Adherence to NICE Guidance .................................................................................................................. 6 Audit Requirements .................................................................................................................................. 6 Date of Review ......................................................................................................................................... 6 Glossary ................................................................................................................................................... 7 References ............................................................................................................................................... 7 Governance Approvals ............................................................................................................................. 7 Appendix 1 – Evidence Review ................................................................................................................ 8 Appendix 2 – Lifestyle factors and causes of secondary hyperhidrosis ................................................... 13 Appendix 3 – NICE Clinical Knowledge Summary – Hyperhidrosis ......................................................... 14 Appendix 4 – Diagnostic and Procedure Codes ...................................................................................... 15 Appendix 5 – Version History ................................................................................................................. 16 GM Hyperhidrosis Policy v3.2 FINAL Page 4 of 17 Policy Statement Greater Manchester Health and Care Commissioning (GMHCC) Effective Use of Resources (EUR) Policy Team, in conjunction with the GM EUR Steering Group, have developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission treatments/procedures in accordance with the criteria outlined in this document. In creating this policy GMHCC/GM EUR Steering Group have reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). Equality & Equity Statement GMHCC/CCGs have a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act 2012. GMHCC/CCGs are committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its functions, GMHCC/CCGs will have due regard to the different
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