We would strongly disagree with the subtitle of this editorial (6 May 2000)-"Surgery and botulinum toxin are treatments of choice in severe cases." Collin and Whatling dismiss conventional medical therapy with anticholinergic drugs as "inconvenient, unpleasant and temporary. Patients usually stop using anticholinergic drugs because of a dry mouth."
The truth is exactly the opposite. Surgery is only rarely necessary and the editorial quite properly warns of numerous surgical pitfalls which include recurrence of hyperhidrosis, almost certain impotence, compensatory sweating, permanent neurological damage from anoxia and death (their words). Botulinum toxin, which they recommend for axillary or plantar hyperhidrosis, requires 12 injections per axilla and "tedious and uncomfortable 24-36 injections per foot." Even this horrendous procedure gives only 11 months relief and antibody formation may reduce long term efficiency.
The logical treatment is surely with anticholinergic drugs. We have used Glycopyrronium bromide (Robinul) 2mgs up to three times daily for 25 years with great success. The majority of patients we see are young women, whose hyperhidrosis is ruining their lives. Robinul greatly improves their quality of life and the inevitable dry mouth is accepted unreservedly.
Young women do not suffer any other unwanted effects, though it is obvious that older men (who do not as a rule present to us with hyperhidrosis) may well have problems with vision and micturition. The North East Thames Regional Drug Information Service could find no evidence of any long term side effects; some patients have used it for years.
Michael Klaber
Consultant Dermatologist and Hon Senior Lecturer.
Broomfield Hospital, Chelmsford, CM1 7ET
Michael Catterall
Consultant Dermatologist
Basildon Hospital, Basildon, SS16 5NL
http://www.bmj.com/content/321/7262/702