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Hyperhidrosis

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Medical Author:

Alan Rockoff, MD

Alan Rockoff, MD

Dr. Rockoff received his undergraduate degree from Yeshiva College with the distinction of Summa Cum Laude. He received his medical degree from the Albert Einstein College of Medicine. His internship and two years of Pediatric residency were at the Bronx Municipal Hospital Center, followed by training in Dermatology at the combined residency program at Tufts and Boston Universities. Dr. Rockoff is certified by both the American Board of Dermatology and the American Board of Pediatrics.

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Medical Editor:

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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What is hyperhidrosis?

Hyperhidrosis, or excessive sweating, is a common disorder which produces a lot of unhappiness. An estimated 2%-3% of Americans suffer from excessive sweating of the underarms (axillary hyperhidrosis) or of the palms and soles of the feet (palmoplantar hyperhidrosis). Underarm problems tend to start around puberty, while palm and sole sweating may begin earlier, often during childhood. Untreated, these problems may continue throughout life.

Sweating is embarrassing, it stains clothes, and it complicates business and social interactions. Severe cases can have serious practical consequences as well, making it hard for people who suffer from it to hold a pen, grip a steering wheel, or shake hands.

What is the cause of hyperhidrosis?

Although neurologic, metabolic, and other systemic diseases can sometimes cause excessive sweating, most cases occur in people who are otherwise healthy. Heat and emotions may trigger hyperhidrosis in some, but many who suffer from hyperhidrosis sweat nearly all the time, regardless of their mood or the weather.

What is the treatment for hyperhidrosis?

Through a systematic evaluation of causes and triggers of excessive sweating, followed by a judicious, stepwise approach to treatment, many people with this annoying disorder can achieve good results and improved quality of life.

The approach to treating hyperhidrosis generally proceeds as follows:

• Over-the-counter antiperspirants: Home remedies like these are usually tried first because they are readily available. Antiperspirants containing aluminum chloride (for example, Certain-Dri) may be more effective when other antiperspirants have failed. So-called "natural" antiperspirants are often not very helpful.



• Prescription-strength antiperspirants: those containing aluminum chloride hexahydrate



• Iontophoresis: a device which passes direct electricity through the skin using tap water



• Oral medications: from the group of medications known as anticholinergics, which reduce sweating



• Botox (botulinum toxin): approved in the U.S. by the FDA for treating excessive axillary (underarm) sweating



• Surgery: cervical sympathectomy, as a last resort

Aluminum chloride hexahydrate

When regular antiperspirants fail, as they often do, to remedy hyperhidrosis, most doctors start by recommending aluminum chloride hexahydrate (Drysol, various generics), a prescription-strength version of aluminum chloride. It is applied just before bedtime seven to 10 nights in a row, then roughly once a week thereafter to maintain improvement. The aluminum salts in this preparation collect in the sweat ducts and block them. Over time, sweating may diminish to the point at which little or no further treatment is needed. This method works reasonably well for many patients whose problem is excessive underarm sweating, but it's not satisfactory for most of those with palm and sole sweating.

The main side effect with aluminum chloride is irritation, which can sometimes, but not always, be overcome by reducing the frequency of use or applying antiinflammatory medications such as lotions containing hydrocortisone.

Iontophoresis

Iontophoresis was introduced over 50 years ago as a treatment for excessive sweating. Its exact mechanism of action is still unclear. The procedure uses water to conduct an electric current to the skin which combats production of sweat. The current is applied typically for 10-20 minutes per session, initially with two to three sessions per week followed by a maintenance program of treatments at one- to three-week intervals, depending upon the patient's response. Iontophoresis treatments sound painful but in fact are not.

Patients purchase devices for this treatment through a doctor's prescription. Medical insurers sometimes cover the cost.

Oral medications

Oral anticholinergic medications such as glycopyrrolate (Robinul) are not commonly used for this condition, because in order to work they often produce side effects like dry mouth, insomnia, and blurred vision.

Botox

Botulinum toxin (Botox), a muscle poison much in the news as a cosmetic treatment for wrinkles, has actually been used in many areas of medicine for some time, such as in the treatment of muscle spasms and certain types of headaches. Its latest medical use is for treating excessive underarm sweating.

Fifty (50) units of Botox are injected into roughly 20 spots in each armpit. This may produce approximately six months of relief from sweating. The injections are uncomfortable, but use of a very small injection needle minimizes discomfort.

Now that this treatment has received FDA approval, many health insurers are providing coverage for the injections and the Botox itself, which is quite costly.

Currently, the FDA has not approved Botox for treating sweating of the palms and soles of the feet, though some physicians are administering it as an off-label use, with some success. Drawbacks of using this treatment for the palms and soles are pain, requiring nerve blocks to numb the hands in order to make the injections tolerable, and the potential for temporary muscle weakness.

Surgery

Endoscopic thoracic sympathectomy (ETS) refers to surgical interruption of the sympathetic nerves responsible for sweating. Sympathectomy is an operation intended to destroy part of the nerve supply to the sweat glands in the skin. The surgeon inserts a special endoscopic instrument into the chest between two ribs just below the armpit. The lung is briefly deflated to better visualize and destroy the nerves. Sympathectomy is both effective and risky. Even with newer endoscopic techniques, complications of the procedure can include excessive sweating in other parts of the body as well as lung and nerve problems. As many of these complications are serious and not reversible, this option is rarely used, and then only as a last resort.

Hyperhidrosis At A Glance

• Hyperhidrosis, or excessive sweating, is a common disorder.
• Axillary hyperhidrosis is excess sweating of the underarms.
• Palmoplantar hyperhidrosis is excess sweating of the palms and soles.
• Hyperhidrosis usually occurs in people who are otherwise healthy.
• The approach to treating hyperhidrosis generally proceeds from OTC antiperspirants to prescription antiperspirants, iontophoresis, oral anticholinergic medications, Botox, and surgery.

Previous contributing editor: Frederick Hecht, MD, FAAP, FACMG