New Research Guides Qbrexza® Palmar Hh Treatment
Since the FDA-approval of the anticholinergic-containing topical cloth called Qbrexza® for the treatment of axillary (underarm) hyperhidrosis, many of us have wondered about off-label use for excessive sweating of the hands. Some clinicians have tried it, but there hasn’t been any published or official guidance as to the most effective and safe regimen – until now!
IHhS co-founder and board member Dr. David Pariser, and his research colleagues (Erin Rivera, MS and Danielle Benedict), recently conducted a study to compare four different ways of using Qbrexza to manage palm sweating. Their results were published in the May 2022 edition of Journal of Drugs in Dermatology. Kudos to Pariser, Rivera and Benedict for following their independent scientific curiosity and making this study happen! Thanks also to their patients for helping to further our understanding of Hh treatments and best practices by taking part in the project! (More chances to participate in research are coming soon, so watch your email inbox and make sure you are subscribed to receive our messages.)
“People suffering with excessive sweating of the hands don’t have a lot of treatment options," says Pariser, "so it was logical to try a treatment proven to be effective on the underarms to see if it would work on the hands. We conducted this study in a scientific way to determine the best way to use the anticholinergic cloths on the hands. The results described in this article were published in a dermatology journal so that everyone could benefit from the knowledge.”
In the study, the researchers assigned palmar hyperhidrosis patients to four different groups – each applying the Qbrexza topical cloth to their palms once a day for four weeks in a slightly different manner:
- Leaving the medication on the hands for 15 minutes before washing them
- Leaving the medication on the hands for 30 minutes before washing them
- Leaving the medication on the hands overnight before washing them
- Leaving the medication on the hands for 30 minutes with occlusion (occlusion is a non-breathable barrier on top of the skin) and then washing them.
The researchers’ goal was to find the Qbrexza administration routine for the hands that delivered the optimal balance of high efficacy (benefit), and low side effects.
One hundred and twenty patients, age nine years or older with self-reported excessive palm sweating took part in the study, which lasted four weeks and consisted of one of the above daily application routines. There were twelve participants aged 9-15 years and nine participants aged 16-17 years. The oldest participant was 56 years old. Seventy-three females and forty-seven males took part. Ten participants were multi-racial, 19 Black, and 80 white. The average length of time the participants reported having had hyperhidrosis was about 20 years.
All participants were instructed to wipe both their hands continuously with one Qbrexza cloth until the cloth was dry (about 3 minutes) to ensure that all the medication in the cloth was being applied. This significantly differs from Qbrexza application instructions for underarms, which are to wipe each underarm just once with the cloth. The researchers asked the palmar patients to apply the cloth for longer because the skin on the palms is thicker than in the underarms, and they theorized it would take more medication to have an effect on the palms.
After using the cloth for three minutes to apply the medication to their hands, patients in three of the groups were instructed to put on clean cotton gloves and wear the gloves for either: 15 minutes, 30 minutes, or overnight. Those in the fourth group were told to put on occlusive (non-breathable) gloves and wear those for 30 minutes instead of cotton gloves. After the appropriate time period, patients in each group were told to take off the gloves and wash their hands thoroughly with warm water and soap, and to dry them. This was a very important step to help prevent the transfer of any of the anticholinergic medicine to the eyes where it can cause mydriasis (pupil dilation). Despite this, mydriasis was still the most common side effect seen in the study, presumably from the inadvertent introduction of the medication into one or both eyes.
Three out of the 120 study participants did not complete the study due to side effects which were: for one patient, blurred vision, urinary hesitancy (difficulty urinating) and pupil dilation; for the second patient, burning and itching of the treatment area; and for the third patient, pupil dilation that didn’t resolve after three days. A few other participants had side effects, likely from systemic absorption of the medication into the body, and these were seen at about the same rates as when people use Qbrexza for the underarms; they were not severe enough to make these participants leave the study. Any skin reactions reported by participants were described as mild and resolved on their own.
As the study went on, it became clear that those patients using occlusion (the non-breathable gloves) were getting the least results from Qbrexza, perhaps (the researchers theorized) because occlusion causes more sweating, which then can dilute – or “wash out” - the medication.
The study found that the application of the Qbrexza cloth onto both hands (until the cloth was dry or about 3 minutes), wearing clean cotton gloves for 30 minutes, and then washing the hands achieved the best sweat-reducing results with the most acceptable safety profile. For this group, “hand sweat severity” dropped an average of 4 points out of a 10-point scale.
Another interesting discovery from the study: it seems that palmar hyperhidrosis patients may need to allow more time than axillary hyperhidrosis patients for Qbrexza to start to work for them. While previous research has shown that underarm excessive sweating is noticeably reduced after one week of daily Qbrexza use, this study found that palms respond more slowly and the researchers recommend that any future studies of Qbrexza for the palms be longer than 4 weeks. The researchers also recommend more studies of Qbrexza to determine exactly how effective this treatment can be for excessive palmar sweating. It should also be noted that in the U.S., health insurance companies may not provide coverage for off-label treatments, such as this one. Ideally, the makers of Qbrexza (we hope you are reading this!) would pursue additional labeling from the FDA to make palmar Hh an official indication for this treatment. If there is any movement in that direction, we will let you know!
Qbrexza is currently marketed by Journey Medical Corporation of Scottsdale, Arizona. The research discussed here was initiated, however, when Qbrexza was owned by Dermira Inc., a wholly owned subsidiary of Eli Lilly and Company. The Board of Directors of the International Hyperhidrosis Society, in their treatment algorithms, currently recommends Qbrexza as a first-line treatment for primary axillary hyperhidrosis (underarm excessive sweating). Depending upon how treatment of the palms with Qbrexza seems to be working, based on our board’s clinical experiences, we might consider updating the palmar treatment algorithms. Again, we will let you know if that is the case.
PRO TIP: Healthcare providers interested in meeting and talking to this study’s lead investigator, Dr. David Pariser, should plan on attending an International Hyperhidrosis Society Master Class. EmailChristine@SweatHelp.org and include “Hh Master Class” in the subject line of your email and you’ll be added to our VIP Early Alert mailing list for registration details. We can’t wait to hear from you!
Hyperhidrosis sufferers should know that Dr. Pariser and his colleagues are incredibly committed to helping hyperhidrosis patients, you can find his Virginia practice details here. Or, use our Clinician Finder to locate other IHhS-Educated practitioners. Want to support our research and education? Please donate today!
Ready to dig even deeper on this topic? Read the full study here:
Open-Label Cohort Study to Evaluate Efficacy and Safety of Application of Glycopyrronium Cloth, 2.4% for Palmar Hyperhidrosis
Journal of Drugs in Dermatology, May 2022
David M. Pariser MD, Erin Rivera MS, Danielle Benedict
Department of Dermatology, Eastern Virginia Medical School and Virginia Clinical Research, Inc, Norfolk, VA.