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Treatment of Hyperhidrosis
Revision Date(s) 07/14/14; 07/08/13; 07/10/12; 05/10/11; 04/13/10; 05/12/09; 04/08/08; 06/12/07; 03/08/05; 06/08/04; 03/09/04; 09/12/03; 11/12/02; 09/07/99
Primary Focal Hyperhidrosis
Treatment of primary (focal) hyperhidrosis may be considered medically necessary when 1 or more of the following medical complications are present:
*FDA approved indication.
Ongoing/repeat treatments may be considered medically necessary to maintain improvements in physical function.
Treatment of primary (focal) hyperhidrosis is considered not medically necessary in the absence of physical functional impairment or medical complications associated with the condition.
Secondary Hyperhidrosis
Treatment of secondary (gustatory) hyperhidrosis may be considered medically necessary when 1 or more of the following medical complications are present:
*FDA approved indication.
Treatment of secondary gustatory hyperhidrosis is considered not medically necessary in the absence of physical functional impairment or medical complications associated with the condition.
A multispecialty working group (1) defines primary focal hyperhidrosis as a condition that is characterized by visible, excessive sweating of at least 6 months' duration without apparent cause and with 2 or more of the following features:
Hyperhidrosis Disease Severity Scale (HDSS)
To evaluate the severity of hyperhidrosis, the Hyperhidrosis Disease Severity Scale (HDSS) questionnaire (2) provides a quantitative measure of severity and impact on daily life before and after treatment. Patients rate their symptom severity using the following scale:
Scoring: 1:mild, 2:moderate, 3-4:severe
Iontophoresis device HCPCS code
There are no specific HCPCS codes for the durable medical equipment [DME] used for iontophoresis therapy. The following nonspecific code may be used:
Botulinum toxin HCPCS codes:
Botulinum toxin products are unique biologic agents and are not interchangeable with each other. Not all of the botulinum toxin products listed are indicated for treatment of hyperhidrosis (See Regulatory Status).
Note: This policy provides medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Unique clinical circumstances may warrant individual consideration, based on a review of applicable medical records.
Definition of Terms
Hyperhidrosis, or excessive sweating, can lead to impairments in psychological and social functioning. Various treatments for hyperhidrosis are available, such as topical agents, oral medications, botulinum toxin, and surgical procedures.
Hyperhidrosis may be defined as excessive sweating, beyond a level required to maintain normal body temperature in response to heat exposure or exercise. It can be classified as either primary or secondary. Primary focal hyperhidrosis is idiopathic in nature, typically involving the hands (palmar), feet (plantar), or axillae (underarms). Secondary hyperhidrosis can result from a variety of drugs, such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or underlying diseases/conditions, such as febrile diseases, diabetes mellitus, or menopause.
Secondary hyperhidrosis is usually generalized or craniofacial sweating. Secondary gustatory hyperhidrosis is excessive sweating on ingesting highly spiced foods. This trigeminovascular reflex typically occurs symmetrically on scalp or face and predominately over forehead, lips, and nose. Secondary facial gustatory sweating, in contrast, is usually asymmetrical and occurs independently of the nature of the ingested food. This phenomenon frequently occurs after injury or surgery in the region of the parotid gland. Frey syndrome is an uncommon type of secondary gustatory hyperhidrosis that arises from injury to or surgery near the parotid gland resulting in damage to the secretory parasympathetic fibers of the facial nerve. After injury, these fibers regenerate, and miscommunication occurs between them and the severed postganglionic sympathetic fibers that supply the cutaneous sweat glands and blood vessels. The aberrant connection results in gustatory sweating and facial flushing with mastication (chewing). Aberrant secondary gustatory sweating follows up to 73% of surgical sympathectomies and is particularly common after bilateral procedures.
The consequences of hyperhidrosis are primarily psychosocial in nature. Symptoms such as fever, night sweats, or weight loss require further investigation to rule out secondary causes. Sweat production can be assessed with the Minor starch iodine test, which is a simple qualitative measure to identify specific sites of involvement.
A variety of therapies have been investigated for primary hyperhidrosis, including topical therapy with aluminum chloride, oral anticholinergic medications, iontophoresis, intradermal injections of botulinum toxin, endoscopic transthoracic sympathectomy, and surgical excision of axillary sweat glands. Treatment of secondary hyperhidrosis focuses on treatment of the underlying cause, such as discontinuing certain drugs or hormone replacement therapy as a treatment of menopausal symptoms.
Topical iontophoresis (the use of an electric current to introduce various ions through the skin) is a long-standing treatment of palmar or plantar hyperhidrosis and recently adapted for axillary hyperhidrosis. The mechanism of action is not precisely known, but is thought to be related to plugging of the sweat gland pores. The U.S. Food and Drug Administration (FDA) regulates iontophoresis devices via the 510(k) process.
In tap water iontophoresis (TWI) treatment, the patient places his/her hands or feet into a tap water bath that contains two electrodes, or positions an electrode device in the armpit(s). A small electric current passes through the electrodes. Patients are treated for 20-30 minutes, with treatments every 2 to 3 days for 5 to 10 sessions before an effect is observed. After euhidrosis (perspiration cessation) is achieved, maintenance therapy may consist of treatment every 1-4 weeks after the initial therapy. Iontophoresis is primarily used for focal palmo-plantar hyperhidrosis, since the hands and feet are the easiest body parts to submerge in water.
Botulinum Toxin
Botulinum toxin is a potent neurotoxin that blocks cholinergic nerve terminals; symptoms of botulism include cessation of sweating. Therefore, intracutaneous injections have been investigated as a treatment of gustatory hyperhidrosis and focal primary hyperhidrosis, most frequently involving the axillae or palms. The drawback of this approach is the need for repeated injections, which have led some to consider surgical approaches
Surgical treatment options include removal of the eccrine glands and/or interruption of the sympathetic nerves. Eccrine sweat glands produce an aqueous secretion, the overproduction of which is primarily responsible for hyperhidrosis. These glands are innervated by the sympathetic nervous system. Surgical removal has been performed in patients with severe isolated axillary hyperhidrosis
Surgical Intervention
Various surgical techniques of sympathectomy may also be tried. The second (T2) and third (T3) thoracic ganglia are responsible for palmar hyperhidrosis, the fourth (T4) thoracic ganglion controls axillary hyperhidrosis, and the first (T1) thoracic ganglion controls facial hyperhidrosis. Various surgical techniques of thoracic sympathectomy have been investigated as a curative procedure, primarily for combined palmar and axillary hyperhidrosis that is unresponsive to non-surgical treatments. While accepted as an effective treatment, sympathectomy is not without complications. In addition to the immediate surgical complications of pneumothorax or temporary Horner's syndrome, compensatory sweating on the trunk generally occurs in a majority of patients, with different degrees of severity. Medical researchers have investigated whether certain approaches, e.g., T3 versus T4 sympathectomy, result in less compensatory sweating, but there remains a lack of consensus about which approach best minimizes the risk of this side effect. In addition, with lumbar sympathectomy for plantar hyperhidrosis, there has been concern about the risk of post-operative sexual dysfunction in men and women.
The outcome of different surgical and medical treatment modalities is best assessed by using a combination of tools. Quantitative tools include gravimetry, evaporimetry, and Minor's starch iodine test. Qualitative assessment tools include general health surveys and hyperhidrosis-specific surveys. Of these, the Hyperhidrosis Disease Severity Scale (HDSS) has been found to have a good correlation to other assessment tools and to be practical in the clinical setting.
Regulatory Status
Drysol™ (aluminum chloride [hexahydrate] 20% topical solution, Person and Covey, Inc.) is approved by the U.S. Food and Drug Administration (FDA) to be used as an aid in the management of hyperhidrosis in the axillae (underarms), palmar (palms of hands), plantar (bottom of feet), and craniofacial (head and face) areas); it is available by prescription.
In 2004 the FDA approved botulinum toxin type A (Botox®) to treat primary axillary hyperhidrosis (severe underarm sweating) that cannot be managed by topical agents. In 2009, this product was renamed to OnabotulinumtoxinA. FDA-approved botulinum toxin* products include:
Note: *Not all of these botulinum toxin products are indicated for treatment of hyperhidrosis.
On July 31, 2009, the FDA approved the following revisions to the prescribing information of botulinum toxin products:
In January 2011, the miraDry® System (Miramar Labs, Inc.; Sunnydale, CA) was cleared by the FDA through the 510(k) process for treating primary axillary hyperhidrosis. This is a microwave device designed to heat tissue at the dermal-hypodermal interface, the location of the sweat glands. Treatment consists of two sessions of approximately one hour in duration. Sessions occur in a physician's office and local anesthetic is used. (FDA Product Code:NEY)
The U.S. Food and Drug Administration (FDA) regulates iontophoresis devices via the 510(k) process. Some machines are only for use by professionals in the office setting. Two devices, commercially available by prescription for home use, are the Drionic® device (General Medical Co., Los Angeles, CA) and the Fisher™ MD-1a Galvanic Unit (R.A. Fischer Co., Northridge, CA).
Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
This policy was created in 1999 and has been reviewed/updated annually with searches of the MEDLINE database. The most recent literature search was performed through May 2014. Following is a summary of the key literature to date:
Aluminum Chloride
Topical products are the first line of therapy in treating primary (focal) hyperhidrosis. Aluminum chloride, like other metallic salts, exerts its anhidrotic effect by obstructing the distal sweat ducts within the acrosyringium by facilitating the formation of a precipitate. (2) Common side effects usually limit the efficacy of the modality to mild cases of hyperhidrosis. For those patients who respond to antiperspirants, long-term use can sometimes result in degeneration of the eccrine unit and resolution of the localized hyperhidrosis. Drysol & Xerac AC are brand names for topical aluminum chloride solution available by prescription. Aluminum chloride is predominantly used to treat axillary hyperhidrosis, however additional indications include use on the hands, feet and scalp.
Iontophoresis became recognized as a practical approach in the treatment of hyperhidrosis in 1968. No large randomized trials have been performed, but several smaller trials (n=3–112) suggest significant benefit with 81.2% of patients having a positive result after 8 treatments. (3) Most iontophoretic systems use direct current (DC) although alternating current (AC) can also be used or AC with DC offset (AC⁄DC). Lesser side effects are associated with devices that use AC⁄DC. Frequent side effects of treatment include irritation, dry, peeling, and cracked skin at the treatment site, especially in the axillary area.
Case series include a 2013 study from Ireland with 28 patients. (4) Patients received a minimum of 9 treatments over 21 days in a clinical setting. Twenty of the 25 patients (80%) for whom data were available after hospital administration of tap water iontophoresis reported a moderate or great amount of improvement in symptoms and a moderate or great improvement in quality of life (according to a Disease Life Quality Index). After the initial course of treatment, 13 patients chose to purchase a home iontophoresis device. Eight of the 13 (62%) reported that home iontophoresis was 'much less effective' than hospital treatment. No other outcomes e.g., symptom improvement, were reported following home use.
A 2014 retrospective case series from Turkey included 21 pediatric patients under age 18. (5) Most of the patients (n=16) had palmoplantar hyperhidrosis. Nineteen patients completed the course of 21 tap water iontophoresis sessions. Among study completers, the mean self-report treatment effectiveness score rated on a 0 to 10 visual analog scale (VAS) was 6.36 at the end of treatment. Seventeen of 19 patients (89.5%) reported a 50% or more decrease in sweating at the end of treatment.
Section Summary
It is acknowledged that only small case series provide limited evidence that iontophoresis is an effective treatment of hyperhidrosis. Controlled trials are needed to determine whether iontophoresis improves the net health outcome in patients with hyperhidrosis. However, after topical aluminum chloride, iontophoresis is a second line treatment that may be considered for palmar or plantar hyperhidrosis, but is frequently too irritating for regular use in the axilla.
Botulinum toxin type A
A considerable body of published literature addresses botulinum toxin injection for the treatment of axillary and palmar hyperhidrosis and substantiates the efficacy of this treatment. (6-14) Studies include multiple randomized placebo-controlled trials evaluating Botox, a botulinum toxin type A product. In addition, another botulinum toxin A product, Dysport, has been evaluated in RCTs for treatment of axillary hyperhidrosis (14) and palmar hyperhidrosis (9). Moreover, a small RCT published in 2007 compared Botox and Dysport and found similar levels of efficacy and safety with the two products. (11)
One of the larger RCTs was published in 2007. (13) This study was an industry-sponsored multicenter double-blind, placebo-controlled efficacy and safety study of botulinum toxin type A in patients with persistent bilateral primary axillary hyperhidrosis. Enrollment criteria included a resting sweat production of at least 50 mg/axilla in 5 minutes and a rating of 3 or 4 (underarm sweating barely tolerable or intolerable, and frequently or always interferes with daily activities) on the Hyperhidrosis Disease Severity Scale (HDSS). A total of 322 patients were randomized to receive 50 U, or 75 U of Botox or placebo. Retreatment after 4 weeks was allowed in subjects with at least 50 mg of sweat (per axilla) over 5 minutes and an HDSS score of 3 or 4. Following the first injection, 75% of subjects in the Botox groups showed at least a 2-point improvement in the HDSS, compared with 25% of subjects in the placebo group. Sweat production decreased by 87% (75 U), 82% (50 U), and 33% (vehicle). (Similar results were obtained in patients requiring a second treatment.) The median duration of effect was 197, 205, and 96 days (75 U, 50 U, and vehicle, respectively). Seventy-eight percent of subjects (252) completed the 52-week study; 96 of 110 (87%) in the 75-U group, 83 of 104 (80%) in the 50-U group, and 73 of 108 (68%) in the control group. Intent-to-treat analysis at 52 weeks showed a responder rate (greater than 2-point improvement on the HDSS) for 54 (49%) subjects in the 75-U group, 57 (55%) in the 50-U group, and 6 (6%) in the placebo group. Injection-site pain was reported in about 10% of all groups, with a mean duration of 2.4 days (10-day maximum).
No placebo-controlled RCTs were identified evaluating the safety and efficacy of the newest formulation of botulinum toxin A, Xeomin. Two double-blind randomized trials have compared Xeomin to Botox. In 2014, Campanati et al included 25 patients with moderate to severe primary palmar hyperhidrosis resistant to aluminum chloride or iontophoresis. (15) Patients received injections of Xeomin in a randomly selected hand and Botox in the other hand. The botulinum toxin was given at a fixed dosage per cm2 of the hand. There were no statistically significant differences in outcomes between groups. This included changes in the HDSS and the extent of sweating assessed using the Minor test. Previously, in 2010, Dresser et al published a double-blind RCT with 46 patients with bilateral axillary hyperhidrosis and a previously stable Botox treatment for at least 2 years. (16) Patients received 50 MU of Botox in one randomly selected axilla and 50 MU Xeomin in the other axilla. All patients completed the study.. According to patient self-report in structured interviews, there were no between group differences in therapeutic effect including onset latency, extent and duration and no differences in injection site pain. Moreover, clinical examination did not identify any differences between the 2 sides in the diffuse sweating pattern.
There is less evidence in support of botulinum toxin type A for treating plantar hyperhidrosis. No RCTs or large uncontrolled studies were identified; most published studies are case reports or small case series.
The evidence evaluating botulinum toxin A use for gustatory hyperhidrosis as a result of Frey syndrome includes noncontrolled or nonrandomized studies, all showing favorable treatment outcomes. The patient inclusion criteria were variable across the studies and case reports; ages varied (16 to 87 years); patients had undergone varied types of parotid surgery (i.e., bilateral, partial); not all studies documented gustatory sweating with Minor's starch test as part of the patient screening.
Section Summary
Multiple RCTs support the efficacy and safety of botulinum toxin A for treating severe axillary and palmar hyperhidrosis. There is a lack of RCTs on use of botulinum toxin A for plantar hyperhidrosis and gustatory hyperhidrosis.
Botulinum toxin type B
There was one placebo-controlled randomized trial on botulinum toxin B (Myobloc) for treating primary axillary hyperhidrosis and one on palmar hyperhidrosis. Both studies were by Baumann and colleagues and were published in 2005; neither discussed whether patients had failed previous treatments for hyperhidrosis. The study on axillary hyperhidrosis included 20 participants; they received subcutaneous injections of Myobloc (2,500 U or 0.5 mL per axilla) (n=15) or placebo (n=5). (17) Patients who received placebo were offered Myobloc at subsequent injections. One patient in the placebo group did not return for follow-up and another responded to placebo and did not return for a subsequent Myobloc injection. Data were available on Myobloc efficacy for the remaining 18 participants (15 in the initial Myobloc group and 3 crossovers). There was a statistically significant improvement in axillary hyperhidrosis according to patient and physician subjective assessment from baseline (before receiving an active injection) to Day 30. Details on the efficacy outcomes were not reported. The mean length of time to return to baseline levels of sweating in these 18 patients was 151 days (range 66 to 243 days). Sixteen participants reported 61 adverse events over the course of the study. Five of 61 adverse events (8.2%) were determined to be definitely related to the study; 4 axillary bruising events and 1 instance of pain at the injection site. Eleven adverse events (18%) were determined to be probably related to study treatment; dry eyes (n=3), dry mouth (n=5) and indigestion (n=3). Flu-like symptoms were reported by 6 of 20 patients (30%); however, the study period coincided with flu season. Note that the authors did not compare the active treatment and placebo groups in their analysis.
The RCT on Myobloc for treatment of palmar hyperhidrosis included 20 participants with excessive palmar sweating. Fifteen participants received injections of Myobloc (50,000 U per palm) and 5 received placebo. (18) Nonresponders were offered an injection of Myobloc at day 30. At day 30, the two quality-of-life measures were significantly higher in the Myobloc group compared to the control group. However, there was not a statistically significant difference in efficacy in the physician analysis of the palmar iodine starch test at day 30 (p=0.56). No further details were provided on the efficacy outcome measures described above. The mean duration of action according to self-report in 17 patients (15 in the initial treatment group and 2 who crossed-over from the placebo group) was 3.8 months (range, 2.3 to 4.9 months). Participants were asked about specific adverse events. Eighteen of 20 (90%) reported dry mouth/throat, 12 (60%) reported indigestion, 12 (60%) reported excessively dry hands, 12 (60%) reported muscle weakness, and 10 (50%) reported decreased grip strength. Both studies by Baumann and colleagues were limited by a small sample sizes and limited or no comparative data.
A small randomized trial by Frasson et al in Italy that compared botulinum toxin type A and type B for treating axillary hyperhidrosis was published in 2011. (19) This study included 10 patients with idiopathic focal axillary hyperhidrosis that was unresponsive to other non-surgical treatments. Patients received 50 U botulinum toxin A in one axilla and 2,500 U botulinum toxin B in the contralateral axilla. Gravimetry was performed at baseline and follow-up as an objective measurement of sweat production. In addition, the sweat area was photographed. At each follow-up point, the decrease in sweat weight from baseline was significantly greater on the botulinum toxin B side compared to the botulinum toxin A side. For example, after 1 month, the sweat weight in 5 minutes was 13% of the baseline value on the botulinum toxin A side and 4% of the baseline value on the botulinum toxin B side (p=0.049). By 6 months, the sweat weight returned to 91% of baseline on the botulinum toxin A side and 56% of baseline weight on the botulinum toxin B side (p=0.02). Findings were similar for sweating area. All patients tolerated injections of botulinum toxin types A and B well and none reported systemic adverse effects. The authors commented that this study used a higher dosage of botulinum toxin B than previous studies.
A 2013 RCT by Ibrahim et al compared botulinum toxin B and suction-curettage in 20 patients with primary axillary hyperhidrosis. (20) Patients received 1 treatment in 1 axilla and the other treatment in the contralateral axilla. The primary outcomes were reduction in the sweat rate in resting and exercise- induced states at 3 months. The mean percent reduction in the resting sweat rate at 3 months was 72.1% in the botulinum toxin group and 60.4% in the suction-curettage group; the difference between groups was not statistically significant, p=0.29). Similarly, the exercise-induced sweat rate did not differ between groups at 3 months. The mean percent reduction was 73.8% in the botulinum toxin group and 58.8% in the suction-curettage group, p=0.10. Scores on the validated 4-point HDSS, however, did differ significantly between groups at 3 months and favored botulinum toxin B treatment. The difference in the decrease in HDSS scores between the botulinum toxin and suction-curettage groups at 3 months was 0.80 points, p=0.0002. Although findings of this single small trial are not conclusive, study findings suggest that botulinum toxin B may be at least as effective as suction-curettage for treatment of primary axillary hyperhidrosis.
Section Summary
There are few RCTs evaluating botulinum toxin type B for treating hyperhidrosis. One small placebo-controlled RCT did not clearly demonstrate the efficacy of botulinum toxin type B in patients with palmar hyperhidrosis. Two RCTs support the efficacy of this treatment for patients with axillary hyperhidrosis. An additional RCT in patients with axillary hyperhidrosis compared botulinum toxin type B with suction- curettage and found that botulinum toxin type B resulted in outcomes that did not differ significantly from suction-curettage.
Microwave treatment
A 2012 RCT evaluated a microwave device for treating hyperhidrosis. (21) This device applies microwave energy to superficial skin structures with the intent of inducing thermolysis of the eccrine and apocrine sweat glands. This industry-sponsored double-blind study randomized 120 adults with primary axillary hyperhidrosis in a 2-to-1 ratio to active (n=81) or sham (n=39) treatment. Treatment consisted of 2 sessions, separated by approximately 2 weeks. Patients who responded adequately after 1 session or declined further treatment did not need to undergo the second session and a third procedure was allowed within 30 days for participants who still had a high level of sweating after 2 sessions. All patients in the sham group had 2 sessions. In the active treatment group, 11 individuals (9%) had only 1 session and 10 (8%) had a third procedure. The primary efficacy endpoint was a score of 1 (underarm sweating never noticeable) or 2 (underarm sweating tolerable) on the Hyperhidrosis Disease Severity Scale at the 30-day follow-up; HDSS score at 6 months was a secondary outcome. A total of 101/120 (84%) completed the study. At 30 days, 89% of the active treatment group and 54% of the sham group had an HDSS score of 1 or 2; p<0.001. At 6 months, 67% of the active treatment group and 44% of the sham group had an HDSS score of 1 or 2; the difference between groups remained statistically significant, p=0.02. Unblinding occurred at 6 months. Twelve-month data were available for the active treatment group only; 69% reported an HDSS score of 1 or 2. There were 45 procedure-related adverse events in 23 (28%) of the active treatment group and 5 (13%) of the sham group. The most frequently reported adverse event was altered sensation; no serious adverse events were reported. Compensatory sweating was reported by 2 individuals in each group and had a mean duration of 52 days. The authors noted that study data provided an opportunity to identify areas for improvement of the treatment protocol including waiting longer between treatments and using a higher dose of energy at the second session.
A 2012 industry-sponsored case series reported on 31 patients with primary axillary hyperhidrosis who were treated with microwave therapy using the miraDry system. (22) All patients had an HDSS score of 3 or 4 at baseline. The primary efficacy outcome, the proportion of patients whose HDSS decreased to 1 or 2 was 28 (90%) at 6 months and 12 months after treatment. Longer-term skin-related side effects (that all resolved over time) were altered sensation in the skin of the axillae (65% of patients, median duration, 37 days) and palpable bumps under the skin of the axillae (71% of patients, median duration, 41 days).
Section Summary
A single RCT and case series provides insufficient evidence that microwave treatment improves the health outcome for primary focal hyperhidrosis. This RCT reports short term benefit of microwave treatment in reducing hyperhidrosis, but also reports a high rate of skin-related side effects such as pain and altered sensation. Additional controlled studies with long-term follow-up in the treatment and control groups, a longer period of blinding and a consistent treatment protocol are needed to confirm the efficacy of this treatment, and to better define the risk/benefit ratio.
Radiofrequency ablation
A 2013 study evaluated radiofrequency ablation as a treatment option for patients with severe bilateral palmar hyperhidrosis resistant to conservative treatment. (23) The study was conducted in Turkey and retrospectively reviewed outcomes after radiofrequency ablation (n-48) or transthoracic sympathectomy (n=46). Patients were not randomized to treatment group. After the mean of 15 months follow-up, palmar hydrosis was absent in 36 patients (75%) in the radiofrequency ablation group and 44 patients (96%) in the surgery group. The difference in outcomes was statistically significant between groups, favoring the surgical intervention, p<0.01. Six patients in each group reported moderate or severe compensatory sweating (p=0.78).
Section Summary
One non-randomized comparative study represents insufficient evidence on radiofrequency ablation as a treatment of hyperhidrosis. In this single available study, radiofrequency ablation was found to be inferior to surgical sympathectomy.
Surgical interventions
Tympanic neurectomy for gustatory hyperhidrosis
Review articles by Clayman et al. (24) and de Bree et al. (25) describe the various medical and surgical treatments for Frey's syndrome. Tympanic neurectomy is described as a treatment for Frey's syndrome, with satisfactory control reported in 82% of patients. In addition, this surgical treatment is generally definitive without a need for repeated interventions.
Sweat gland excision for primary focal hyperhidrosis
Surgery may involve removal of the subcutaneous sweat glands without removal of any skin, limited excision of skin, and removal of surrounding subcutaneous sweat glands, or a more radical excision of skin and subcutaneous tissue en bloc. (26) Depending on the completeness of surgical excision, the treatment is effective in 50–95% of patients.
Transthoracic sympathectomy for primary focal hyperhidrosis
Several RCTs and one meta-analysis have compared different approaches to surgery; there were no sham-controlled RCTs. In 2011, Deng and colleagues published a meta-analysis of data from RCTs and observational studies published to 2010 evaluating thoracoscopic sympathectomy for patients with palmar hyperhidrosis. (27) The authors pooled outcome data from different approaches to sympathectomy, i.e., single-ganglia blockage (T2, T3, or T4), and multi-ganglia blockage (T2-3, T2-4, or T3-4). (Note: T refers to rib). Based on these analyses, they concluded that T3 (11 studies) and T3-4 (2 studies) had the "best" clinical efficacy i.e., postoperative resolution of symptoms. The T3 approach resulted in a 97.9% pooled efficacy rate, and the T3-4 approach resulted in a 100% pooled efficacy rate. In the studies for which data were available, the pooled rate of postoperative compensatory sweating was 40% after T3 surgery. Data on compensatory sweating after T3-4 surgery was only available from one study with 60 patients; a pooled analysis could not be performed.
Subsequent RCTs have also compared levels of sympathectomy. A 2011 study by Baumgartner and colleagues included 121 patients with disabling palmoplantar hyperhidrosis. (28) Patients were randomized to receive bilateral sympathectomy over T2 (n=61 patients) or T3 (n=60 patients). Six of 121 (5%) patients, 3 in each group, were considered treatment failures i.e., had recurrent palmar sweating to a bothersome level. There were no significant differences between groups in the reported subjective change in plantar or axillary sweating after surgery. At 6 months, the mean level of compensatory sweating (0 to 10 severity scale) was 4.7 (SD=2.7) for the T2 group and 3.8 (SD=2.8) for the T3 group (p=not significant). Similarly, at 1 year, the mean severity rating of compensatory sweating was 4.7 (SD=2.5) in the T2 group and 3.7 (SD=2.8) in the T3 group; p=0.09. A trial by Ishy et al in Brazil compared surgery at the T3 and T4 levels and a trial by Yuncu et al in Turkey compared surgery at the T3 and T3-4 levels. Ishy et al included 20 patients with palmar hyperhidrosis. (29) All patients experienced complete bilateral remission of palmary sweating after 1 year of follow-up. The level of compensatory sweating did not differ significantly between groups at 1 week, 1 month, or 6 months, but at 1 year, there was a significantly higher rate in the T3 compared with the T4 group (20/20, 100% in the T3 group and 15/20, 75% in the T4 group, p=0.47). Yuncu et al included 60 patients with axillary hyperhidrosis; 17 were assigned to T3-4 surgery and 43 to T3 surgery. (30) There were no significant differences between groups in postoperative satisfaction. At the 1-year follow-up, the incidence of compensatory sweating was lower in the T3 group (79%) than the T3-4 group (100%).
There is also a large amount of data from case series on transthoracic sympathectomy for treating primary focal hyperhidrosis (31-36) Case series generally report high success rates for palmar and axillary hyperhidrosis, although there are potential adverse effects, most commonly compensatory sweating.
For example, in 2010, Wait and colleagues published a retrospective analysis of prospectively collected data on patients who underwent bilateral thoracoscopic sympathectomy for hyperhidrosis. (35) Data were available on 322 of 348 (93%) of patients who underwent surgery. Patients' previous use of nonsurgical hyperhidrosis treatments was not reported. Complete resolution of symptoms was experienced by 300 of 301 (99.7%) with palmar hyperhidrosis, 136 of 186 (73%) with axillary hyperhidrosis, 27 of 30 (90%) with craniofacial hyperhidrosis, and 19 of 197 (9.6%) with plantar hyperhidrosis. Compensatory sweating was reported by a total of 201 of 322 (62%) patients. The compensatory sweating was severe in 20 (6.2%) of patients and mild or moderate in 181 (56.2%) of patients. It is worth noting that thoracoscopic sympathectomy was performed in some cases of plantar hyperhidrosis and that there was a low rate of success. In addition, when reporting rates of compensatory sweating, the authors did not distinguish between mild and moderate levels of symptoms, although these could have different clinical implications for the patient.
In 2011, Smidfelt and Drott in Sweden reported on long term outcomes after transthoracic sympathectomy (36) Of 3015 patients who had been treated with endoscopic thoracic sympathectomy for hyperhidrosis and/or facial blushing, 1700 (56%) responded to a written survey after a mean of 14.6 (SD=2.4) years. The most common indications for surgery were palmar hyperhidrosis (n=795 47%) and facial blushing (n=536, 32%). A total of 85.1% of respondents reported that they had a satisfactory and lasting effect of the surgery. Sweating and/or blushing recurred and were considered a problem in 8.1% and 6.9% reported no initial effect or a poor effect. No or insignificant compensatory sweating was reported by 425 (25.6%) respondents. Compensatory sweating was considered troublesome by 299 (17.6%), annoying by 409 (24.1%), severe by 367 (21.6%) and incapacitating by 190 (11.2%). Nearly half of the patients who underwent surgery did not respond to the survey; their outcomes may have been different from those of study respondents.
A 2013 series reported on complications after thoracic sympathectomy in 1731 patients with palmar, axillary or craniofacial hyperhidrosis. (37) Thirty days after surgery, 1531 (88.4%) of patients reported compensatory sweating. Among the 1531 patients, compensatory sweating was mild in 473 (31%) moderate in 642 (42%) and severe in 416 (27%). Gustatory sweating was reported by 334 of the 1731 (19%) patients.
Section Summary
RCTs and a meta-analysis of RCTs support the efficacy of transthoracic sympathectomy at various levels for palmar and axillary hyperhidrosis. These data are complemented by case series which have found high efficacy rates, but also high rates of compensatory sweating for these conditions. There is insufficient evidence in support of transthoracic sympathectomy for treating plantar hyperhidrosis; case series found lower rates of efficacy for plantar compared to axillary or palmar hyperhidrosis, and there are concerns for side effects in sexual functioning. There are insufficient data to conclude that any particular approach to surgery results in lower rates of compensatory sweating.
Endoscopic lumbar sympathectomy for primary plantar hyperhidrosis
No RCTs were identified but several case series were identified. A 2009 series by Rieger and colleagues from Austria evaluated surgery results in 90 patients (59 men, 31 women with severe plantar hyperhidrosis). (38) Thirty-seven patients (41%) had only plantar hyperhidrosis, and 53 (59%) had plantar and palmar hyperhidrosis. All patients had previously used other treatments including topical aluminum chloride therapy. There were a total of 178 procedures–90 on the right-side and 88 on the left side. The technique involved resecting a segment of the sympathetic trunk between the third and fourth lumbar bodies together with the ganglia (L3 and/or L4). After a mean follow-up of 24 months (range: 3 to 45), hyperhidrosis was eliminated in 87 of 90 patients (97%). Postoperative neuralgia occurred in 38 (42%) patients between the 7th and 8th day. The pain lasted less than 4 weeks in 11 patients, 1-3 months in 19 patients, 4-12 months in 5 patients, and more than 12 months in 3 patients. Three men reported temporary sexual symptoms; one was incapable of ejaculation for 2 months. None of the women reported postoperative sexual dysfunction.
In 2010, Reisfeld reported on results of a U.S.-based study from a specialized hyperhidrosis clinic in which bilateral endoscopic lumbar sympathectomy was performed in 63 patients with focal plantar hyperhidrosis. (39) There were 13 (21%) male patients and 50 (79%) female patients. A clamping method was used in which clamps were placed at L3 (46.6%), L4 (52.4%), and L2 in one case. There was a learning curve with this procedure, and 5 early cases had to be converted to an open procedure. Fifty-six (89%) of the patients had previously undergone some form of thoracic sympathectomy, and all had tried conservative measures. After a mean follow-up of 7 months, all patients considered their plantar hyperhidrosis symptoms to be "cured" or "improved;" 97% reported "cure." All of the patients with previous thoracic sympathectomy had some degree of compensatory sweating. After lumbar sympathectomy, 51 of the 56 patients (91%) reported that their compensatory sweating was unchanged. In the 7 patients who did not have a previous thoracic sympathectomy, 1 reported mild and 6 reported moderate compensatory sweating. The authors stated that no sexual problems were reported by the male patients, and they did not discuss possible sexual problems among the female patients.
It is worth noting, that in contrast to earlier concerns about this procedure being associated with risks of permanent sexual dysfunction in men and women, the recent case series did not find any instances of permanent sexual dysfunction. A 2004 review from a multi-specialty working group on hyperhidrosis stated that lumbar sympathectomy is not recommended for plantar hyperhidrosis because of associated sexual dysfunction; this article did not cite any data documenting sexual dysfunction. (1) To date, there are very few studies on endoscopic lumbar sympathectomy for focal plantar hyperhidrosis and no comparative studies.
Section Summary
There are insufficient data supporting the safety and efficacy of lumbar sympathectomy for treating primary plantar hyperhidrosis.
There is insufficient evidence on the efficacy and safety of microwave treatment for treating hyperhidrosis and on radiofrequency ablation for palmar hyperhidrosis. There is evidence from randomized trials that botulinum toxin improves the net health outcome for patients with axillary hyperhidrosis and evidence that botulinum toxin A products improve the net health outcome for palmar hyperhidrosis. Because of the limited number of studies and high rates of adverse effects, there is insufficient evidence that botulinum toxin B improves the net health outcome for patients with primary palmar hyperhidrosis. There is insufficient evidence on the efficacy of any botulinum toxin products for other types of primary hyperhidrosis, including plantar and secondary hyperhidrosis.
Regarding surgical treatments for hyperhidrosis, data from randomized controlled trials and observational studies show high rates of efficacy of endoscopic transthoracic sympathectomy for primary focal hyperhidrosis, with the exception of plantar hyperhidrosis. However, there are high rates of compensatory hyperhidrosis which must be considered in the treatment decision. There are insufficient data to draw conclusions on the efficacy of endoscopic lumbar sympathectomy in patients with primary plantar hyperhidrosis.
Practice Guidelines and Position Statements
Society of Thoracic Surgeons
In 2011, an expert consensus statement on the surgical treatment of hyperhidrosis was published by a task force of the Society of Thoracic Surgeons. (40) The document states that endoscopic thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis. They further recommend the following treatment strategies (with R referring to rib and the number to which rib):
The National Institute for Health and Care Excellence issued guidance in 2014 stating that there is sufficient evidence of the efficacy and safety of endoscopic thoracic sympathectomy (ETS) for primary facial blushing to support the use of the procedure. (41)
American Academy of Neurology
In 2008, the American Academy of Neurology (AAN) created guidelines for use of botulinum neurotoxin for the treatment of autonomic disorders and pain. (42) These guidelines include the following recommendations for botulinum toxin injection as a treatment of hyperhidrosis:
Thoracoscopy, surgical; with thoracic sympathectomy
Chemodenervation of eccrine glands; both axillae
Other area(s) (e.g., scalp, face, neck), per day
Sympathectomy, thoracolumbar
Sympathectomy, lumbar
Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential
Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
ICD-9 Procedure
Injection, onabotulinumtoxinA, 1 unit
Injection, abobotulinumtoxinA, 5 units
Injection, rimabotulinumtoxinB, 100 units
Injection, incobotulinumtoxinA, 1 unit
Unclassified drugs (may be used to report aluminum chloride 20%)
Surgical, peripheral nervous system, destruction, sympathetic nerve, percutaneous endoscopic
Surgical, peripheral nervous system, excision, head and neck sympathetic nerve, code by approach (percutaneous or percutaneous endoscopic)
Type of Service
Medicine / Surgery
Place of Service
Inpatient Outpatient
Add to Therapy Section - New Policy
Replace Policy - Policy reviewed without literature review; new review date only.
Replace Policy - Policy updated regarding iontophoresis as a treatment for hyperhidrosis based on 2003 TEC Assessment; policy statement revised to indicate that this is considered investigational (previously considered medically necessary). Policy changed from "AR" to "BC."
Replace Policy - Policy revised regarding surgical treatments of axillary hyperhidrosis; surgical excision considered medically necessary, axillary liposuction considered investigational.
Replace Policy - Correction to policy statement to remove surgical excision of axillary sweat glands from investigative statement in Policy Section.
Replace Policy - Policy updated with literature search; policy statement unchanged.
Codes updated - No other changes.
Disclaimer and Scope updates - No other changes.
New PR Policy - Policy replaces BC.8.01.19. In the treatment of primary hyperhidrosis, treatment is considered medically necessary when physical functional impairment exists; and cosmetic when no physical functional impairment is present; axillary liposuction is considered investigational. Botox is indicated as medically necessary treatment for secondary gustatory hyperhidrosis. Definitions of physical functional impairment, cosmetic and reconstructive surgery added to Benefit Application section.
Code updated - CPT code 89230 deleted as directed by RPIW 11/8/07.
Replace Policy - Policy statement regarding aluminum chloride, iontophoresis, botulinum toxin, endoscopic transthoracic sympathectomy and surgical excision of axillary sweat glands changed from "cosmetic" to "not medically necessary" when there is no physical functional impairment. Description, Rationale and Reference sections updated.
Replace Policy - Policy updated with literature search; no change to policy statement. References added.
Code update - 68409 & 64818 added, no other changes.
Code Update - 89230 added back to policy.
Code Update - New 2010 code added.
Replace Policy - Policy updated with literature search; no change to policy statement.
Codes Updated - Additional J Codes added.
Replace Policy - Policy updated with literature search; no change to policy statement. Reference added.
Replace policy. An extensive reformatting of policy statement was done to mirror the layout of Blue Cross Policy 8.01.19 Treatment of Hyperhidrosis. Added Microwave treatment as investigational for primary focal hyperhidrosis. The Description and Rationale sections have been updated. Reference 2 replaced. Added CPT 69676 tympanic neurectomy and 97033 application of modality iontophoresis. Added ICD-9 procedure 99.27 Iontophoresis, added J3490 unclassified drugs, J0588 Injection, incobotulinumtoxinA, 1 unit.
Update Coding Section – ICD-10 codes are now effective 10/01/2014.
Replace policy. Policy statement has addition of radiofrequency ablation as investigational for treatment of palmer hyperhidrosis. Rationale updated based on a literature review through May 2013. References 4, 19, 20 and 32 added; other references renumbered or removed. Some policy sections reformatted for readability. Policy statement changed as noted.
Annual Review. Policy updated with literature search through May, 2014. References 5, 15, 20, 41 added; others renumbered/removed. Policy statements unchanged.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).


text: Thursday Mar 27 2008 comments Earth Hour By: Ben Furtado -A +A Ben Furtado/Auburn JournalJulie Magee helps promote Earth Hour by passing out fliers door to door at the Crest View apartments in Auburn, Thursday. Ben Furtado/Auburn JournalBy going door to door Julie Magee hopes to spread the word about Earth Hour. Click Here

subset: commoncrawl


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Highlighting cases studies in "climate-smart agriculture" from around the globe, a new FAO publication shows that many rural communities are already successfully making the transition to new forms of farming better suited to the rigors of a warmer world. FAO's Leslie Lipper has more details.
The document can be found by clicking on the following link: http://www.uncclearn.org/fao_success_stories_climate_smart_agriculture


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Tactical Sales Training
Typical sales training focuses on how to close deals rather than open doors. Many sales professionals have solid closing skills, but could be better armed with the tactical playbook necessary to further fill their pipelines and get in the door with senior executives. Our award-winning Sales Prospecting Training is a combination of classroom work, role-playing, and live calls on speakerphone in front of the class. Participants leave the program feeling energized and motivated to build a culture of excitement around unearthing new business opportunities for growth.
Customized Sales Training Curriculum
Vorsight customizes our on-site workshops to meet client specifications. Below is an outline of topics covered in our tactical sales training workshops:
- Prospecting, Direct Lines, 3x3 Research, & Social Media
- Talking Points, Messaging, & Conversation Skills
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- Effective Questioning Skills
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- Planning, Process, & Time Management
- Management Toolkit
- Qualifying & Buying Questions
Sales Prospecting Training Inquiry
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text:
WINSTON-SALEM, N.C. - Travis McKie's first season at Wake Forest ended with a long losing streak.
No matter what happens now, at least his last one won't.
The Demon Deacons snapped a seven-game slide Tuesday night with a 62-57 win over a Clemson team trying to play its way into the NCAA tournament.
"When you lose seven in a row, a lot of things go wrong - everything you do is wrong," McKie said. "Getting on the other side of the column is great. Now we just have to keep moving forward and keep getting better."
Devin Thomas and Tyler Cavanaugh each scored 12 points in Wake Forest's victory.
The Demon Deacons (15-13, 5-10 Atlantic Coast Conference) erased an early 10-point deficit and shot 55 percent against the league's second-stingiest defense.
Frustrating the Tigers by mixing a couple of zone defenses, they held on to avoid just their third winless February since the school started keeping complete records in 1951 and delivered a serious blow to Clemson's NCAA tournament chances.
"I'm sure it hurts it a lot," Clemson coach Brad Brownell said.
"Just losing hurts, though. We don't want to lose any game, and to lose it the way we did where we were kind of in control at halftime was disappointing. ... We're kind of learning as we go on this journey."
Damarcus Harrison scored 15 points for the Tigers (17-10, 8-7), who pulled within two points on Jaron Blossomgame's three-point play with 29.1 seconds left.
After Cavanaugh made it a four-point game with two free throws with 20.7 seconds left, Rod Hall missed on a contested drive. McKie added a free throw with 8.2 seconds remaining.
K.J. McDaniels - the league's third-leading scorer - had 10 points on 3-of-11 shooting and missed six of seven attempts from 3-point range.
"Our best player had a tough night," Brownell said. "He hasn't had many, but tonight was a night he struggled a little bit, and we just didn't have enough other guys play well enough to carry us in the second half."
They almost did.
Harrison hit back-to-back 3-pointers to pull Clemson to 56-54 with 2 minutes left.
But with his team down by two with 1:39 left, McDaniels missed two free throws. The rebound was tapped out to Codi Miller-McIntyre, and the Wake Forest guard jetted toward the bucket and hit a layup through contact from Hall. His free throw made it 59-54 with 1:34 left.
Hall finished with 10 points for Clemson, which managed just one field goal during the 6½-minute span in which Wake Forest took the lead for good and fell to 2-19 at Joel Coliseum.
Arnaud William Adala Moto scored 11 points. Miller-McIntyre finished with 10, three days after the guard was held scoreless in a 33-point loss at rival North Carolina.
That marked Wake Forest's seventh straight loss, its longest slide since McKie was a freshman in 2010-11 on coach Jeff Bzdelik's first Demon Deacons team that dropped its final 11.
"I believe we lost our confidence," Bzdelik said. "It was shook, which happens to anybody. ... It should be back. Our guys fought through it, and I'm really proud of them."
They outscored Clemson 13-2 down the stretch and went up 55-46 on Thomas' layup with just under 4 minutes left.
They were down 10 before rallying to take a 35-34 lead with 15½ minutes left on Adala Moto's alley-oop lob to McKie, and it stayed tight until the Demon Deacons' big run.
Hardly anybody saw this coming, after Wake Forest spent the entire month of February in a free-fall with four of six losses in the month coming by double figures.
Meanwhile, Clemson had won two straight and certainly had plenty to play for.
And early on, the Tigers appeared on their way to their sixth straight victory in the series after they held Wake Forest without a rebound for a stretch of 8½ minutes and kept the Demon Deacons completely off the offensive glass in the first half.
Yet the Tigers' only double-figure lead came with their best player on the bench: McDaniels sat for most of the final 5 minutes of the half with two fouls. Clemson went up 30-20 on Harrison's short jumper with about 1:45 left before the break.
Follow Joedy McCreary on Twitter at http://twitter.com/joedyap
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The Super Bowl is an exciting event, but like any big gathering, it poses security risks. Where there are security risks, there are often human-canine teams whose job it is to secure the area and keep it safe for everyone.
iStock photo
[1] http://www.thebark.com/print/2878?page=show
[2] http://www.thebark.com/printmail/2878?page=show
[3] http://www.thebark.com/category/author/karen-b-london
[4] http://dfw.cbslocal.com/2011/01/28/dogs-sniffing-around-nfl-sites-for-safety/


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Adam Vinatieri
Indianapolis Colts
|Auction Value
By Nick Fields, Colts Correspondent, Tue, Aug 12th 2:45pm EDTVinatieri only made one of two field goals in the Colts first preseason game against the Jets. He uncharacteristically pushed a 29 yard attempt wide just before the end of the first half. (Source: IndyStar)
Fantasy Impact: Some people question how much longer Vinatieri can be one of the elite kickers in the NFL as he enters the season as one of the oldest players at 41 years of age. Although he missed a short field goal during the Colts first preseason game, there is no reason to worry because it was just that, a preseason game. Last year Vinatieri made a career high 35 field goals and converted 19 of 23 attempts from 40-plus yards out. He may be 41 years old, but his leg strength and accuracy are as good as ever. Expect another big season from Vinatieri as the Colts offense is expected to take another step forward towards being among the league's elite.
No recent player news or notes available


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With the construction of the new parking garage and a pedestrian walkway now under way, officials from East Tennessee State University are encouraging students returning to campus this fall to allow additional time for finding a parking space.
Parking will be available, but with the closure of some areas, ETSU Vice President for Finance and Administration Dr. David Collins said some students may not be able to use the same parking lots they have relied on in the past.
"Even on our busiest days during previous semesters, we always had between 100 and 150 open spaces in parking lot 22A, which sits on the corner of Greenwood Drive and Jack Vest Drive behind Earth Fare," Collins said. "We will rely on that lot this fall, and we encourage students to enter that area from Greenwood Drive rather than through campus. The BUCSHOT shuttle service has four pick-up locations at lot 22A and has multiple drop-off points across campus."
Persons parking in lot 22A and lot 21, which is directly behind Warf-Pickel Hall, will need to follow a different walking pathway onto campus that goes around the construction site. Barricades and signage will be placed to identify that pathway.
Collins added that ETSU has also created a new parking area at the baseball stadium on University Parkway where students, faculty and staff can park and ride the shuttle to campus. That new parking lot alone will provide approximately 300 spaces.
During the first six weeks of the semester, overflow parking and shuttle service will also be available at BucVillage behind campus off Southwest Avenue.
"Even though we have temporarily lost between 300 and 400 spaces due to the construction, accommodations have been made to adjust for that loss," Collins said.
He added that students, faculty and staff will need to adjust their driving route now that the center part of campus has closed to traffic. On June 4, ETSU closed the intersection of Alexander Drive and Sherrod Drive at Ball Hall, as well as the intersection of Ross Drive and Sherrod Drive at Sam Wilson Hall. This was done as part of an effort to create more green space and walkway areas and to eliminate vehicular traffic at a location that has a high number of pedestrians. Collins recommended that unless drivers want to access the parking lot between Brown Hall and Alexander Hall (University School), they should avoid entering campus on Sherrod Drive, which is between Brown Hall and the ETSU/MSHA Athletic Center and across from the Carnegie Hotel entrance.
Disability parking spaces in those areas have been relocated to the circle in front of Gilbreath Hall and to lot 37, which is between Sam Wilson and Lamb Hall.
ETSU parking attendants will be stationed on campus to assist commuters with information on parking lot occupancy.
Collins said that with the exception of the areas where major construction projects are taking place, other student parking lots, such as those in front of Centennial Hall and lot 9, which is located across the street from Pal's Sudden Service, will continue to be available.
ETSU broke ground last week on the $26.1 million student parking garage that is scheduled to be complete in fall 2013. Once finished, it will provide approximately 1,224 new spaces.
Collins strongly urges students and employees to visit HYPERLINK "http://www.etsu.edu/detour" www.etsu.edu/detour to view the parking map and read the "Frequently Asked Questions" section.
"The safety of our students and employees is our highest priority, and we ask everyone to be patient during this temporary time of construction," he added. "Simply arriving early and allowing time for parking will make a tremendous difference."