By Gary M. White, MD
Hyperhidrosis is excessive sweating. It is most common on the palms, soles and axilla. Many patients are unaware that hyperhidrosis is a recognized medical condition, much less that there is treatment available.
There are four to five million sweat glands on the body, with the highest concentrations on palms, soles, and axillae. Sweating of the palms and soles can begin at birth. Sweating of the axilla begins at puberty. Palmar/plantar sweating is controlled solely by the cerebral cortex. It does not occur when patient is asleep or under general anesthesia. Axillary sweating is related to emotional issues or thermoregulation. Humans can sweat three to four liters per hour to maintain thermal homeostasis. In hyperhidrosis, sweat glands are of normal size, density, location, and histologic appearance.
Excessive sweating usually symmetric in any of several regions. Most common of axillae, palms, soles, and craniofacial region. Excessive sweating may be a social handicap and even an occupational hazard. Social isolation may result from wet palms as patients are embarrassed. The simple act of holding hands on a date can be traumatic. Onset for the majority is before age 30, with many in early childhood.
Focal, visible, excessive sweating of at least 6 months duration without apparent cause with at least 2 of the following characteristics:
[Multi-specialty Working Group on Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis, 2003] ￼￼
Some "clinical strength" antiperspirants can help. These are applied to dry skin BID.
Aluminum chloride 20% in alcohol (Drysol in the US) applied QHS to dry skin should be tried initially and as control is achieved, taper to 1-3 times per week. This approach is usually quite effective in the axilla but often fails on the palms and soles. Local irritation is the main potential side effect. The FDA allows up to 15% aluminum chloride to be sold OTC.
Oral anticholinergic medications include glycopyrrolate 1 mg QD-TID, and propantheline bromide 15 mg Q4-6 hours. They can be very effective. Potential side effects include dry mouth, dry eyes, and urinary retention. Patients must be counseled that this approach can stop sweating all over and caution must be taken not to get overheated (risk of heat stroke) if outside on warm days. Typically one starts glycopyrrolate 1 mg po daily x 7 days, then if control is not achieved, BID x 7 days, and TID if needed. The patient should stop escalating the dose once control is achieved.
For children, glycopyrrolate is FDA-approved for 3-16 year olds for severe chronic drooling caused by neurologic disorders. Treatment is off-label for hyperhidrosis. It comes as Cuvposa, a cherry-flavored solution at 1 mg/5 cc. Make sure to discuss with parents the potential side effects, including dry eyes and mouth. In one study of 31 children with hyperhidrosis (mean age 15 years), the average age of onset was 10.3 years and at a mean dosage of 2 mg daily, 90% of patients experienced improvement [JAAD 2012;67:918-23].
Topical glyocpyrrolate 2% in clinical studies has been effective [JEADV 2016; 30;2131].
Oxybutynin (comes as 5 mg/5 cc) has been found to be a good treatment option for children [Pediatric Dermatology 2014;31:48–53]. In that study, children weighing more than 40 kg received 2.5 mg of oxybutynin once daily in the evening for 7 days, then 2.5 mg BID from day 7–21 and then 5 mg BID. Patients weighing < 40 kg received the same treatment for the first 3 weeks, but their dose was not increased after day 21. The most common side effect was dry mouth. In one study of adults with generalized hyperhidrosis [BJD 2015;173;1163–1168], the oxybutynin was started at 2.5 mg per day and increased gradually until it reached an effective dose, without exceeding 7.5 mg per day. Sixty percent of patients experienced some improvement, compared with 27% of patients receiving placebo.
Iontophoresis (low level electric current) is very effective but requires time and money. Patients usually need to rent or buy the machine. Device instructions vary, but in general, patients immerse the affected hands or feet in a shallow tray filled with tap water for a short period of time (20 to 40 minutes) while the device sends a mild electrical current through the water. Treatment is home-based and performed 2-3 times per week until control is achieved, then tapered as able.
Subcutaneous injections of botulinum A toxin can give benefits for 3-6 months. The main downside however is the pain of injection. Ice has been enthusiastically recommended to reduce the pain [Dermatol Surg 2007;33;588]. Additionally, up to 1/3 of patients whose hands are treated may experience decreased grip strength. Ulnar and median nerve blocks at the wrist level may be performed to reduce the pain of palmar injection. Patients should understand that the axillary injections may not reduce body odor as the eccrine glands (not apocrine) are targeted. Duration of efficacy seems to increase with repeated injections [JAAD 2014;70;1083].
Various reports have supported the efficacy of laser for axillary hyperhidrosis.
A cosmetic laser, Precision TX™, reportedly provides significant sweat reduction in 80% of patients six months after a single treatment.
In one study, one to two treatments using the 1064 nm Nd:YAG resulted in an average sweating reduction of 93% as measured by starch-iodine tests at 1-3 months after treatment [Journal of the Laser and Health Academy Vol. 2011]. Eighty-seven percent of patients assessed their final sweating reduction as better than 50%. Seven of them (22%) had results in the range of 76-100% reduction.
Others have reported benefit using lasers with 924 nm and 975 nm wavelengths.
Endoscopic transthoracic sympathectomy (ETS) is highly effective for disabling cases of the palms, axillae, and face. However, side effects of this procedure include sudden cardiac death, pneumothorax, hemothorax, gustatory facial sweating, compensatory hyperhidrosis at other sites and Horner's syndrome.
For the feet, application of a creamy "clinical strength" antiperspirant and/or aluminum chloride 20% (Drysol) at night is recommended. Some benefit from wearing two pairs of socks--the one in contact with the skin 100% polyester and the outer sock 100% cotton. botulinum A toxin may be injected, but is painful.
Hyperhidrosis localized to the nose after surgery.
Starch-iodine Test at Acta Dermato-Venereologica 2015;95;364. An iodine solution is applied. After it dries, starch is sprinkled on the area. The starch-iodine combination turns black wherever there is excess sweat.
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