Dr. Richards has a specific interest in treating localized sweating and accepts direct visits for sweating. Other skin problems require physician referral. OHIP covers office visits. Your sweating problem is assessed and treatment options reviewed.
Excess local sweating is commonly seen in the underarms, palms, soles, upper forehead and scalp, between and under the breasts, pelvic creases, and lower back. The cause is unknown, but it often runs in families, and may begin in children or adults.
This information is derived from a medical literature review;-- and from our sweat treatment experiences during the past decade. Careful reading may save you a visit, as we outline several self treatment methods. There are many advertisements for sweat care products and procedures. Advertiser self interest and experience can influence a presentation. Read critically. Speak to others who have undergone sweat treatment.
Aluminum salts: Aluminium chloride or aluminium chloride hexahydrate at 1-4%, combined with deodorant, is the most common ingredient in standard under-arm anti-perspirants. Hyperhidrosis requires greater concentrations. To minimize irritation, these stronger products are best applied at bedtime. Be certain the skin is dry, as these products may irritate moist skin. If tolerated, a second application in the morning is beneficial. Start slowly with a low concentration and increase as tolerated. These products may take a few days to take effect.
Examples are: Xerac AC 6.5%, Certain Dri Pads 12.5%, Hydrosal 15% +2% salicylic acid, Drysol 20%. A pharmacist can increase percentages, but local irritation is limiting. Adjust concentration to the skin area. ie: full strength on palms and soles but mild on the face. Gloves or Saran wrap at night, over palms and soles, increases penetration and results. Skin irritation can be reduced by hydrocortisone 1% cream (non-prescription in USA but prescription in Canada) or non-prescription hydrocortisone ½ % cream.
Topical glycopyrrolate( Secure Pads 1-3%):---particularly for the face.
Available at www.pharmacy.ca (1-800-727-5048); 311 Sherbourne Street (at Gerrard), Toronto, Ontario, M5A 3Y1. (Please inform us of other distributors). Studies from Britain and South Korea, showed these pads to be effective for facial and scalp sweating. Several of our patients have confirmed this. Studies on other body areas are lacking. Systemic absorption of glycopyrrolate can occur, so read instructions carefully ;--and read the section below on the oral form.
Glutaraldehyde 10% aqueous for feet is available in many pharmacies, and can be applied to the feet by cotton swabs daily, or a few times a week. May be effective, but it produces brownish discolouration, which impairs summer use.
Acetylcholine, which is released from fine nerve endings, stimulates sweat glands to produce sweat. Glycopyrrolate pills are anti-cholinergic and help prevent this release. They work well for all local areas;- and particularly well for generalized sweating. Common side effects (dose related) are dry mouth (the major issue), blurred vision, dilated pupils, headaches, nervousness, urinary retention, constipation, sedation, and rapid heartbeat. Continued dry mouth may increase dental cavities. Use in pregnancy has not been studied. Two recent articles suggest that side effects are well tolerated by about 50% of patients. Some use for short-term emergency use. Chewing sugarless gum may help dryness. Take care with hot weather exercise when sweating required. Glycopyrrolate is worth a trial!
Glycopyrrolate has limited availability. It was used for decades to treat stomach ulcers, but more effective treatments replaced it. Trade names are Avert (Canada) and Robinul (USA). These non-prescription pills are available at www.pharmacy.ca in 0.5mg, 1mg, 1.5mg and 2mg tablets. Individual response varies. Start slowly with 0.5 mg, Gradually increase to 1 to 2mg two to three times a day as tolerated. They can also be used, with care, in children. Other anti-cholinergic drugs such as prescription oxybutynin (Ditropan 5 mgms) 1-2x a day are available. Comparative articles are not available but glycopyrrolate is the most recommended. Propanolol 5-10 mgms is sometimes used by performers and others to reduce anxiety induced sweating and tremor but it has no specific role in hyperhidrosis.
Botox has revolutionized sweat treatment.—especially of the underarms.
Vials of Botox Therapeutic
Botox injections work well for nearly all cases of underarm sweating. Most achieve a 90% improvement and last an average of 5-7months. Range 3-13. The Botox injected is identical to cosmetic Botox, but is named:-- Botox Therapeutic;---drug identification number (DIN)- 01981501. Before injecting, we apply iodine, and then cornstarch to the underarms. Sweating areas turn blue and act as an injection guide. Please do not apply an anti-perspirant before the procedure. You may return immediately to all activities. Botox has been used for underarms since 1997 and there are no reports of side effects at these low doses. There can be mild injection bruises. Sweating in other areas occurs normally as before. Beneficial effects show in 1 to 4 days, and are maximum within a week. Deodorants can be used immediately. Botox is not approved for use in pregnancy or breast feeding, or in individuals with myasthenia gravis or similar neurological problems. Can be used in older children, teens, and adults. Most patients do not require it, but if your skin is sensitive, then an icepack is applied. You can also pre-apply a numbing agent such as:-- EMLA, Benzocaine gel, Maxilene, or Xylocaine gel 2%.
One vial of Botox contains 100 units and costs about $435 plus dispensing fee (2 vials a bit less). For small underarms, one vial does both sides. Larger underarms and most men require 2 vials. Most private insurance plans cover Botox for hyperhidrosis (OHIP does not). Prior authorization is often required and we provide an insurance form. We do not supply Botox vials, but write a prescription for them. Neither OHIP or insurance companies cover our injection fees. Our total injection fee for both under-arms is $225. No HST.
Wet shirt from sweating
A conclusive starch iodine test
A moderate starch iodine test
Injecting Botox to underarm
Botox is 90% effective for palmar sweating. One hundred units are given to each palm, but large men’s hands require 150. We use an ice pack, and then an innovative cool refrigerant; spray (about which we have written and lectured). This spray is applied to each injection site and is very helpful in reducing sensations. We perform the actual hand injection in under 2 minutes. With Botox injections of the palms, there can be temporary (weeks) unpredictable weakening of the fine muscles, so this procedure should be performed carefully on individuals who utilize their hands for fine work (musicians, dentists etc.) or in those who perform vigorous activities requiring strength. Patients rarely may choose to treat only their worst hand. Our injection fee for 2 hands is $275. No HST. After 2 or 3 weeks, the occasional patient may require a 'top-up' with additional Botox. There is no charge for these injections.
Ice pack on palm
Injecting palms using cold spray
Botox injections are performed as per hands and some do well, but satisfactory results are less consistent than with hands. We do not know why failures can occur
Dripping foot, wet floor, and stained shoe
Injecting foot using cold spray numbing
Forehead & Scalp
Botox injections are effective for the upper forehead and frontal scalp and patients often continue with them. After Botox injections, the forehead may feel a bit tighter and occasionally there can be bruising that lasts a few days. One vial is usually adequate. Try Secure pads first.
Botox injections work well in the thigh creases. One vial adequate.
Chest, breasts and back
Botox is effective for sweating between, and under the breasts, and for the lower back
Also called-- auriculotemporal syndrome or gustatory sweating. Can be a side effect of parotid surgery, but can also develop spontaneously. There may be flushing and/or sweating when eating. Botox treatment has been reported by several authors to be effective.
Please try to locate the exact source of your sweating in order that Botox can be administered more precisely.
Please note that our injection fees are not covered by insurance companies.
In Iontophoresis, the hands or feet are placed in plastic pans containing tap water. An electric current is passed through the water for about 20 minutes. Initially, treatments are required every 2 to 3 days. After 2-3 weeks, the interval between treatments can be lengthened to every week or two. Patients operate equipment themselves. If skin irritation develops, this can usually be corrected by moisturizers, a reduction in treatment current, or a prescribed cortisone cream. Some patients find iontophoresis time consuming. Anticholinergic drugs, such as 1-2mgms Avert, can be added to the water to increase effectiveness. These drugs are absorbed and can produce side effects as described under glycopyrrolate pills.
There are a variety of machines, but the literature (and our experience) indicates excellent results with the Fischer MD-1a galvanic unit:-- www.rafischer.com. The machine is available in Canada from West Woodbridge Surgical, telephone 416-248-2040 or 1-800-561-3766, The price is over $1000. We are not aware of insurance companies paying for machines. The battery operated machines are not as powerful as the Fischer machine. Iontophoresis is not approved in pregnancy or in persons with pacemakers or metal implants. Some physiotherapy facilities (hard to find) offer trial iontophoresis treatments for a fee.
Most underarm sweat glands are located centrally. They can be identified by the iodine cornstarch test. The overlying skin and the active underlying sweat glands are surgically removed. Surgery is usually performed under general anaesthetic. Patients will be off work for 1 to 5 days and for about 2-4 weeks if performing physical activities or active sports. Most patients achieve good results, but there is about a 7% failure rate. Compensatory sweating in other parts of the body has not been a problem. Many plastic surgeons perform this surgery and OHIP covers it. Other surgical methods include liposuction and subcutaneous curettage but these are not widely available and are not OHIP covered. I have read about the microwave machine ‘MiraDry’ by Miramar. The preliminary reports are interesting but are company funded. I await independent views and appreciate feedback
This surgery produces dry palms but complications can occur. About 60% get increased (compensatory) sweating in other areas. This OHIP covered surgery is a last resort reserved for severe palmar sweating not responsive to other methods.
Most complaints are for feet, and less for; underarms. Patients should seek advice from family/friends as to whether there is truly an odour;--as frequently, others do not notice it. Air exposure, simple soap, and regular deodorants are often effective. Achieve air exposure by shoe and sock removal, sock changes, arm elevation, and loose cotton clothes. Hair dryers. Odour results from bacterial action on sweat and skin cells. Antiperspirants assist by reducing perspiration and deodorants are fragrances to cover up odours. There are no controlled studies but antibacterial soaps (such as Trisan) are helpful in controlling bacteria and thus odour. Over the counter antibiotic creams (Polysporin) reduce bacterial action. Talcum powders help some, but are messy for others. A non-prescription antibiotic powder Zeasorb may be helpful. Aqueous glutaraldehyde (described above) can assist in foot odour control. Some find commercial products such as “Odour Eaters” helpful.
Dr. Richards is in group dermatology practice in Toronto with Dr. Mary Alice McKenzie, Dr. Smita Amin and Dr. Jan Saksun. Throughout the years, 47 dermatologists have worked in their office.He is a fellow in dermatology of the Royal College of Physicians and Surgeons of Canada and a diplomate of the American Board of Dermatology. He has written 3 books and authored over 50 medical journal papers. He is a director of the Canadian Dermatology Association.
We are located in a medical building at 701 Sheppard Avenue East, Suite 304, at the Bessarion subway stop. The Sheppard bus stops in front of our building and parking is available for $2.00. Detailed directions complete with map can be found below.
or Fax us at 416-590-9842 and our designated hyperhidrosis staff member will telephone you to arrange for an appointment.
From the West:
Take the 401 East to Bayview Ave.
Go North on Bayview to Sheppard Ave. East
Turn Right on Sheppard Ave. East
Proceed to medical builing at 701 Shepard Ave. East (South Side)
From the East:
Take the 401 West to Leslie
Go North on Leslie to Sheppard Ave. East
Turn Left on Sheppard Ave. East
Proceed to Medical Building at 701 Sheppard Ave. East (South Side)
Get off at the Bessarion subway stop
Make your way to Sheppard Ave. East exit
Walk west to Medical Building 701 Sheppard Ave. East