Skip to main content
  1. Right Decisions
  2. Back
  3. Dermatology pathways
  4. Hyperhidrosis
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Hyperhidrosis

Warning

Hyperhidrosis is uncontrollable excessive sweating that occurs at rest, regardless of temperature. In the localized type, the most frequent sites are the palms, soles and axillae. If the history is less typical, e.g. night sweats or if the patient is unwell, there could be a secondary cause.

Secondary hyperhidrosis may be caused by an underlying medical condition and/or as a side effect of a medication or procedure. Underlying medical and/or drug causes for generalised hyperhidrosis should be considered - https://cks.nice.org.uk/topics/hyperhidrosis/diagnosis/assessment/. Hyperhidrosis can be categorized by area of involvement — local versus generalized. The guidance below refers to primary idiopathic hyperhidrosis.

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Mild: A score of 1 or 2 indicates mild or moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box.

Self-care management strategies  

Primary axillary hyperhidrosis: 

  • Commercial antiperspirant rather than deodorant. 
  • Use emollient washes, rather than soap-based products 
  • Avoid tight clothing and man-made fabrics 

Primary Plantar Hyperhidrosis: 

  • Alternate footwear 
  • Moisture wicking-socks, change twice daily 
  • Avoid occlusive footwear such as boots-encourage leather shoes 

Primary focal hyperhidrosis: 

  • 20% aluminium chloride hexahydrate over the counter preparations such as roll-on antiperspirants and spray.  
  • Apply at night just before sleep to skin of the axillae, feet, or hands every 1–2 days as tolerated, until symptoms improve, then use as required. Wash off in the morning. 
  • For craniofacial hyperhidrosis, consider antiperspirant wipes (aluminium chloride) for application to the face (off-label use). 

If skin irritation occurs with aluminium salt preparations, prescribe hydrocortisone 1% cream to be applied once daily for up to two weeks. Also advise soap substitute and to reduce frequency of application until symptoms resolve. 

Moderate: A score of 2 or 3 indicates moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box. 

Oral and topical therapy 

  • Higher strength aluminium salts (up to 50%). 
  • Topical glutaraldehyde or formaldehyde may be used. 
  • Topical glycopyrrolate may be useful for primary craniofacial hyperhidrosis (off-label indication) although is availability is usually within a secondary care setting. 
  • Oral anti-muscarinics such as oxybutynin and glycopyrronium bromide. Beware anti-muscarinic side effects.  

Oral antimuscarinics decrease sweat secretion.  

  • Oxybutynin (standard release): 5mg OD initially, then increase to twice daily. Unlicenced indication.  
  • Propantheline: 15mg TDS one hour before meals. Licenced. Dose could be titrated up to maximum of 120mg/day. 

Patients should be counselled with regards to anti-muscarinic side effects. 

 

 Iontophoresis therapy  

  • Recommended for palms and soles. Axillary treatment is impractical. If unsuccessful, glycopyrronium bromide (an anti-muscarinic agent) may be added to the water. Long term maintenance required.  
  • Iontophoresis machines can be rented/purchased and information regarding this is available on the international hyperhidrosis society website (link below) 

 

Severe: A score of 3 or 4 indicates severe hyperhidrosis.  See hyperhidrosis disease severity scale in clinical resources box. 

Botulinum A Toxin: 

  • Largely used for axillary hyperhidrosis 
  • Can be used for palms, soles, craniofacial hyperhidrosis but treatment is painful in these areas, limiting use. Effects last 6-9 months. 

Surgery  

  • Localized sweat gland resection may be carried out for small areas of axillary hyperhidrosis.  
  • Endoscopic thoracic sympathectomy (ETS) should only be considered when all other options are ineffective or not tolerated.  
  • Complications include compensatory hyperhidrosis elsewhere on the body (very common), pneumothorax (common, gustatory sweating (common), atelectasis, significant bleeding.  

Please note surgical approaches are rarely utilised due to the potential risks involved. 

 

Referral Management

Mild: A score of 1 or 2 indicates mild or moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box. 

Manage in primary care using self-care measures and topical advice. 

See NICE guidance below: 

Refer to the dermatologist to consider specialist management if self-care and topical drug treatments are ineffective/not tolerated. Individual funding requests may be required for certain treatments e.g. Botulinum A Toxin and local availability varies.  

Moderate: A score of 2 or 3 indicates moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box. 

Manage in primary care with oral and topical therapies.  

Refer to secondary care or consultant-led community service for iontophoresis/ Botulinum toxin (if commissioned locally). 

Severe: A score of 3 or 4 indicates severe hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box.

Refer to secondary care or consultant-led community service for iontophoresis and Botox (if commissioned). 

Availability of surgical intervention varies locally and may require individual funding requests. 

 

Clinical tips

  • In the context of generalised hyperhidrosis, consider screening for underlying medical causes  
  • Drug-induced causes of generalised hyperhidrosis include beta blockers, SSRIs, tricyclic antidepressants and opiates. 
  • After a successful trial of iontophoresis, patients may be advised to purchase their own device for long-term maintenance. 

Patient information resources

1. Hyperhidrosis BAD patient information leaflet 

2. NHS information leaflet: Excessive sweating (hyperhidrosis) 

3. Hyperhidrosis UK Support Group leaflet 

4. NHS Inform- Hyperhidrosis 

ICD search categories

Epidermal/Appendageal 

ICD11 code - EE00 

Editorial Information

Last reviewed: 09/06/2023

Next review date: 09/06/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society