Local procedures for axillary hyperhidrosis and osmidrosis: A systematic review of prospective and controlled clinical trials

Axillary hyperhidrosis and osmidrosis are challenging to treat, and neither topical nor systemic drugs have provided optimal treatment outcomes. In the past decades, treatment with botulinum toxin (BTX) has gained status as the gold standard, but it has its limitations both in regard to duration as well as indication for osmidrosis, specifically. A variety of local interventions have been explored in both the surgical field and within energy-based devices (EBDs) for alternative in-office treatments, but a collective overview is lacking. This study sought to investigate and assess the evidence on and effect of current local procedures for axillary hyperhidrosis and osmidrosis. A systematic search for prospective and controlled clinical trials in the databases PubMed, Embase and Cochrane Library until 31 December 2023 was executed. Relevant literature was identified independently by two authors according to predefined inclusion and exclusion criteria. Fifty-nine studies met the criteria for final inclusion, of which 46 studies were randomized controlled trials and 13 were nonrandomized trials. The included studies were classified by procedure type. Individually, a total of 28 studies investigated BTXs, 11 studies explored EBDs, while six studies reported on surgical interventions. Additionally, 14 studies evaluated alternative procedures or investigated combinations and side-by-side comparisons of the different procedure types. The dominant evidence on efficacy and safety was of BTX A. EBDs are increasingly being investigated with microwave thermolysis appearing to be the singular most established and scientifically well-founded method. In the surgical field, less-invasive methods are gaining ground. To meet the increasing demand for individualized treatment, additional high-quality comparative studies are required for the establishment of a future variety of standard treatments.