Excess Local Sweating (Hyperhidrosis)
Excess local sweating (hyperhidrosis) of various local body areas is known as primary focal or localized essential hyperhidrosis. Common areas involved are the underarms, palms, soles, upper forehead and scalp, back and pelvic area.
The cause of primary hyperhidrosis is unknown but often runs in families and can begin at a young age. Axillary (underarm) sweating can stain clothing and produce visible wetness, limit colours worn, and require clothing changes. Palmar sweating often smears ink and curls paper, interferes with computer keyboards and fine tasks and is embarrassing when shaking hands or in other social circumstances. Sweating of the soles can ruin socks, produce sweat marks on shoes, and slipping in sandals and on marble floors. Back and pelvic sweating stain clothes and wet marks are often visible to others. Forehead and scalp sweating can drip, sting the eyes and smear glasses. Embarrassment is common.
No single treatment method is ideal for everyone or for each body site. There is considerable medical and non-medical marketing for a number of treatment options and individuals should do their homework thoroughly (and ask their physician many questions) before proceeding with aggressive techniques. Try to begin as slowly and cheaply as possible and only proceed further if hyperhidrosis is significantly affecting your life.
In recent years the introduction of botulinum toxin A (Botox Therapeutic by Allergan) for the treatment of localized hyperhidrosis has been a major development.
Aluminum salts are the common ingredients in over the counter antiperspirants. Standard products contain 1% to 4%. Severe hyperhidrosis requires much greater concentrations of aluminium chloride or aluminium chloride hexahydrate (usually in alcoholic solutions). Percentages are available up to 35% but the limiting factor with increased percentages is localized burning, stinging and irritation. To minimize irritation, these products should be applied to the affected area gradually at bedtime. Begin slowly with a low concentration and be sure that the skin is dry before application. The products are more irritating if the skin is moist. It may take a few days for the product to take effect. Skin irritation can be reduced by the application of hydrocortisone 1% cream (non-prescription in the USA but prescription in Canada) or non-prescription hydrocortisone ˝ % cream. Antiperspirants are considered the first line of treatment for underarm hyperhidrosis and can be remarkably effective. Numerous products are available: Drysol contains 20% aluminum chloride hexahydrate. Certain Dri are antiperspirant pads containing 12%. Personal preference and price will determine choice of the many brands available. Aluminum salts are more easily tolerated on the palms and soles but don’t seem to be as effective as they are on the underarms. They can be used on the face but begin slowly and take care around the eyes.
Glutaraldehyde 10% aqueous (in water) solution can be made by most pharmacies and can be applied to the feet by cotton swabs daily or a few times a week. It is often very effective but produces a brownish discolouration, which makes it less practical for the hands or underarms.
Dehydral cream (methenamine) is a non-prescription product advertised for localized sweating (most frequently on the feet) but detailed study results are not available.
Secure pads (topical glycopyrrolate from 1 to 3%) are available at www.pharmacy.ca (1-800-727-5048); 311 Sherbourne Street (at Gerrard), Toronto, Ontario, M5A 3Y1. One study from Britain and one from South Korea showed that these pads could be extremely helpful for facial and scalp sweating. Controlled studies on other areas are limited. Systemic absorption of this anticholinergic pad can occur so read the instructions very carefully and read also further information about anticholinergics on page 4.
Botulinum Toxin A (Botox Therapeutic-Allergan):
Underarms (axillae): -- Several medical controlled studies since 1997 have shown that Botox injections are an ideal treatment method for treating underarm sweating in those who have not responded to antiperspirants and who are not committed to surgery. The Botox used is chemically identical to that injected to treat cosmetic lines but is called Botox Therapeutic. The Drug identification number (DIN) is 01981501. Many physicians apply iodine and cornstarch to the underarms before giving the Botox as this outlines the moist sweat gland area. Botox is injected into the underarm area using a fine 30 gauge needle and 50 to 100 units are required for each underarm depending on the size. The procedure takes a few minutes and is not particularly uncomfortable (the occasional person likes an icepack). Individuals may return immediately to work and aggressive activities. Botox has been used for underarm sweating since 1997 and there have been no side effects of concern at these doses. Sweating in other areas will occur normally as before. Botox is not approved for use during pregnancy, breast feeding or in individuals with myasthenia gravis or other neurological problems. Numerous medical articles have indicated excellent results with well over 90% clearing for an average of 5 to 7 months. Beneficial effects show in 1 to 4 days and are at maximum by about a week. Deodorants can be used immediately after treatment. One vial of Botox contains 100 units and costs about $415. Most private insurance plans pay for Botox for excess sweating. Preauthorization is often required. Charges will vary but the average physician charge in Ontario is $200 to $250 to inject both underarms (no HST). Insurance plans do not cover the physician injection charge.
Palms: -- Several studies have demonstrated that Botox is effective for palmar sweating. Ordinarily 100 units are given to each palm (150 for big hands). Palm injections can be uncomfortable but are well tolerated in most individuals with the assistance of ice, cold sprays and / or vibrators. With Botox injections of the palms there can be temporary weakening of the very fine muscles so this procedure should be performed carefully on individuals who utilize their hands for fine work (musicians, dentists and others) or in those whose hands are used for very vigorous activities; rock climbing, baseball, and others. The usual physician fee for injecting both hands is $250 - $300 (no HST). The occasional person just gets their dominant hand-shaking hand treated.
Feet: -- Botox injections for the feet are performed in a manner similar to those for the hands. Fewer studies are available but the available studies confirm their effectiveness.
Forehead & Scalp: -- Botox injections are used for excess sweating of the upper forehead and scalp and a number of articles have confirmed their effectiveness. After Botox the forehead may feel a bit tighter and occasionally there can be bruising that can last a few days.
Pelvic area: -- Medical articles have demonstrated the effectiveness of Botox for localized sweating in the anal area, front pelvic area, and the crease of the upper thighs.
Back: -- A number of medical articles have indicated the effectiveness of Botox for severe localized back sweating.
Frey’s Syndrome: -- Also known as auriculotemporal syndrome or gustatory sweating is a common side effect of parotid surgery. There may be flushing and sweating when eating. This condition can also sometimes occur without surgery. Botox treatment for this condition has been reported by several authors to be effective.
The literature emphasizes that -- individuals should note precisely the source of their sweating so that Botox Therapeutic can be administered to the exact areas.
Iontophoresis - For Palms and Soles:
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 for 5 to 10 sessions before an effect is observed. Once improvement is achieved then the interval between treatments can be lengthened and some patients need the treatment only once every 2 weeks. Patients can operate the equipment themselves. Occasionally slight irritation develops and the palms can become dry or cracked. Slight irritations can be corrected by moisturizers or a reduction in treatment frequency or a prescribed mild cortisone cream. Some patients find Iontophoresis too time consuming.
A number of machines are available but the literature indicates excellent results with the Fischer MD-1a galvanic unit. The unit is made by the R.A. Fischer Co., 517 Commercial Street, Glendale, California 91203-1509, www.rafischer.com. They do not ship to Canada but the machine is available here from West Woodbridge Surgical, telephone 416-248-2040 or 1-800-561-3766; fax 416-248-8822. The current price is $950 to $1200 plus tax. Insurance companies apparently do not cover the cost of machines.
Anticholinergic drugs can be added to the tap water and the effects may last longer. However, these drugs are absorbed into the body and can produce side effects as described under systemic treatments. The battery operated machines are not as powerful as the Fischer machine. Iontophoresis is not approved for use in pregnancy or in persons with pacemakers and / or medal implants.
A few physiotherapy facilities offer trial treatments with iontophoresis and the usual cost is $40 per treatment.
Systemic Treatments (pills – anticholinergics):
The use of pills is usually limited to a few individuals or for short-term use, as their side effects discourage many persons. Commonly found (dose related) are dry mouth, blurred vision, dilated pupil, headaches, nervousness, urinary retention, constipation, sedation and rapid heartbeat. Continued dry mouth can increase dental cavities. They shouldn’t be used during pregnancy or if nursing. Some individuals, however, tolerate anticholinergics very well and find them very effective. They have been used for decades for other conditions and their long-term use appears to be safe, (even if unpleasant for some). There are few controlled studies available on the use of anticholinergics but the most commonly used are glycopyrrolate tablets. The trade name is Robinul in the United States and in Canada, Avert capsules, (non-prescription) 0.5mg, 1mg, 1.5mg and 2mg are available. Other similar anticholinergic drugs are similarly used but there is even less data on them. If your pharmacy cannot obtain these pills; they are available from www.pharmacy.ca as described in the section on topical treatments on page 2. Anticholinergics were used for decades for the treatment of stomach ulcers but newer more effective treatments have replaced them and therefore the pills are sometimes hard to find.
The individual response to anticholinergic drugs varies greatly and individuals usually start slowly with 0.5 mg, gradually increasing to 1 to 2mg two to three times a day as tolerated.
Localized Surgery for Underarm Sweating:
The majority of the sweat glands in the axillae (underarms) are located in the centre. These sweating areas are easily identified by the application of simple tissue paper or by the iodine cornstarch test. The overlying skin and the active underlying sweat glands are removed. This surgical procedure is usually performed under general anaesthetic and patients will be off work for 1 to 5 days and for about 2 weeks if they are performing physical activities or active sports. Most patients are pleased with the long lasting result but there can be approximately a 7% failure rate. Sweating in other parts of the body has not been a problem. Most plastic surgeons perform this localized surgery and it is covered by OHIP. Other surgical methods include liposuction or subcutaneous curettage but this is not widely available in Ontario and is not covered by OHIP.
Endoscopic Thoracic Sympathectomy (ETS) for Palmar Sweating:
This procedure is effective in producing dry palms but complications can occur and it should be a last resort. About 60% get increased (compensatory) sweating in other parts of the body and there can be sweating of the face related to eating. Surgical complications are infrequent but can occur. This surgery is reserved for severe palmar sweating that does not respond to other methods. ETS is covered by OHIP.
This complaint is usually about the feet and less so for the underarms. Patients should seek advice from their family and friends as to whether or not they have an odour, as they sometimes may notice it themselves when others do not. Air exposure, simple soap, and regular deodorants are effective for most. Air exposure means shoe and sock removal when practical, changing socks, elevation of one’s arms to promote more air entry and loose clothes et cetera. Odour results from bacterial action on sweat products and skin cells. Antiperspirants assist by reducing the amount of perspiration and deodorants are fragrances used to cover up odours. There are no controlled studies but antibacterial soaps (such as Trisan) are probably helpful in controlling bacteria and odour. Over the counter antibiotic creams (Polysporin) can reduce bacterial action and may be helpful. Ordinary unscented or scented talcum powders are useful for some. Others find them messy and sticky. A non-prescription antibiotic powder Zeasorb may be helpful. Aqueous glutaraldehyde (described under topical treatments) can be useful in controlling foot odour.
Some individuals do find commercial products such as “Odour Eaters” helpful.
Dr. Richards has a particular interest in localized sweating and accepts direct visits for patients with excess local sweating. Patients with other skin problems do require physician referral. OHIP covers the cost of assessments. The various options discussed in the medical literature are reviewed with you.
Dr. Richards is in group dermatology practice in Toronto with Dr. Mary Alice McKenzie, Dr. Smita Amin and Dr. Michelle Levy. Throughout the years, 45 dermatologists have worked in their office. He is a diplomate of the American Board of Dermatology and a newly elected director of the Canadian Dermatology Association.
Please note this material is for information only and specific details, as they apply to you, should be reviewed with your physician or pharmacist before you commence any treatment procedures.
No Sweat Clinic
Dr. Robert N. Richards M.D., F.R.C.P.
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