title: Treatment of Primary Craniofacial Hyperhidrosis: A Systematic Review.
abstract: BACKGROUND
  Primary craniofacial hyperhidrosis (CH) can have a profoundly negative impact on quality of life. No comprehensive review of its management exists.
  
  
  OBJECTIVE
  The objective of this review is to present the best clinical evidence to guide CH management.
  
  
  METHODS
  A systematic review was performed using PRISMA guidelines. MEDLINE and EMBASE were searched from 1966 to 2014 for articles using the MeSH terms "Hyperhidrosis", "Head", "Neck" and synonymous text words. Inclusion criteria were experimental and observational studies addressing CH treatment. Two reviewers independently assessed study quality and analysed data.
  
  
  RESULTS
  Of 833 references yielded, 27 met inclusion criteria and were analysed. Twenty-two studies evaluated T2 sympathetic ablation (Level III evidence). Outcome measures were subjective and mean follow-up was 29 months. Reported efficacy was high (70-100%), recurrence rates were generally low (0-8%) and complications largely transient (e.g. pneumothorax 0-1%). However, 8-95.4% experienced troubling compensatory sweating. One randomised controlled trial and one observational study evaluated botulinum toxin A (Level Ib and III, respectively). Both employed objective outcome measures and demonstrated similar findings. Efficacy was 100%, lasted a median of 5-6 months and frontalis muscle inhibition was the main adverse effect (50-100%). Three studies evaluated anticholinergic therapy: topical glycopyrrolate demonstrated high efficacy (96%) with minimal adverse effects (Level Ib) and oral oxybutynin demonstrated relatively high efficacy (80-100%) but with noticeable adverse effects (76.6-83.6%) (Level III).
  
  
  CONCLUSIONS
  There are few quality studies evaluating CH treatment. Based on available evidence, we recommend topical glycopyrrolate, oral oxybutynin and intradermal botulinum toxin A as first-line therapies due to their efficacy and safety. T2 sympathectomy should be considered for patients refractory to first-line therapy.
authors.affiliation: Department of Surgery, Royal Free Hospital, Pond St, London, NW3 2QG, UK. rebeccanicholas@ymail.com.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Nicholas
authors.affiliation: Department of Surgery, Royal Free Hospital, Pond St, London, NW3 2QG, UK. ayyazquddus@googlemail.com.
authors.forename: Ayyaz
authors.initials: A
authors.lastname: Quddus
authors.affiliation: Department of Surgery, Royal Free Hospital, Pond St, London, NW3 2QG, UK. Daryll.baker@nhs.net.
authors.forename: Daryll M
authors.initials: DM
authors.lastname: Baker
mesh_terms: D019274:Botulinum Toxins, Type A / Q000627:therapeutic use; D018680:Cholinergic Antagonists / Q000627:therapeutic use*; D005148:Facial Dermatoses / Q000628:therapy*; D015171:Ganglionectomy; D006024:Glycopyrrolate / Q000627:therapeutic use; D006257:Head; D006801:Humans; D006945:Hyperhidrosis / Q000628:therapy*; D008333:Mandelic Acids / Q000627:therapeutic use; D009333:Neck; D009465:Neuromuscular Agents / Q000627:therapeutic use
chemical_list: D018680:Cholinergic Antagonists; D008333:Mandelic Acids; D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A; C005419:oxybutynin; D006024:Glycopyrrolate