Hyperhidrosis Treatment: A Primer

Antiperspirants

Antiperspirants are, of-course, the first line of treatment for hyperhidrosis. Commonly known antiperspirants are easily available over-the-counter in most pharmacies/grocery shops. High strength antiperspirants, which have a higher concentration of aluminum oxide, are also available at pharmacies. Very high strength antiperspirants are usually available only through a prescription, but your dermatologist can provide you with a prescription (or even better, a free sample)

How antiperspirants work?

The main “active” ingredient in all antiperspirants is aluminum based. This aluminum-based compound may consists of several different forms of aluminum such as Aluminum chlorohydrate, Aluminum chloride, Aluminum hydroxybromide or Aluminum zicronium tricholorohydrex glycine, in addition to many others.

When an antiperspirant is applied to the skin it prevents or blocks sweat from reaching the surface of the skin, thus reducing undesired sweat. Once an antiperspirant is applied to the skin, perspiration in the underarm grabs and dissolves the antiperspirant particles, pulling them into the pores and forming superficial plugs that are just below the surface of the skin. When the body senses that the sweat duct is plugged, a feedback mechanism stops the flow. The plugs can stay in place at least 24 hours and then are washed away over time.

Regular Antiperspirants vs. high strength anti-perspirants

While you may begin with using a regular antiperspirant in the affected area, these do not usually provide satisfactory relief from excessive sweat. There are several stronger (clinical strength) and specialized antiperspirants for hyperhidrosis that may be more effective. There are a large number of clinical strength antiperspirant brands available in the market, each with multiple options in terms of strength and form. Many of really high strength antiperspirants for hyperhidrosis may require a prescription in certain markets, while others with a lower strength (but much higher than the regular ones) are available over the counter.

In USA, the FDA allows over-the-counter sale of antiperspirants containing 15%-25% aluminum (with the figure varying based on the specific compound being used).

One thing to note is that Antiperspirants for hyperhidrosis are usually more effective for the underarm region (as compared to hands, feet or face). This is primarily because the skin on palms and feet is much thicker than armpits, thus making absorption of antiperspirant trickier.

Popular over the counter antiperspirants for hyperhidrosis treatment

In general, most over the counter antiperspirants contain some form of aluminum based compound as being the main active ingredient (though there are some exceptions) – mostly aluminum chloride or aluminum chlorohydrate. However, these compounds may result in skin irritation, so other compounds have been gaining popularity in recent years (e.g. aluminum zirconium tetrachlorohydrex glycine). Nevertheless, Aluminum Chloride remains the most popular compound in most OTC antiperspirants.
The following table summarizes the most popular antiperspirants available over the counter in USA. If these do not work for you, your doctor may prescribe a higher strength antiperspirant as well.

Side Effects of Antiperspirants for Hyperhidrosis Treatment

Antiperspirants are generally safe (unless you have any specific reaction to them);. However, aluminum chloride (a common ingredient) may cause mild to moderate skin irritation.

Oral Medication

A qualified medical professional can prescribe you a medication plan that prevents the stimulation of the sweat glands. While such medications often have undesirable side effect, especially for long term usage, they may be considered under certain situations:

• If the patient has tried topical treatments (antiperspirants, Botox, Iontophoresis) unsuccessfully
• If the hyperhidrosis affects body parts that are not amenable to the topical treatments (e.g. scalp, groin, genitals etc.)
• If the patient suffers from compensatory sweating post an ETS surgery

There are several categories of medications for hyperhidrosis treatment, depending on the specific situation of the patient. Some of the major categories of drugs used to treat hyperhidrosis include anxiolytics, anti-cholinergics and antimuscarinics, beta-blockers and antihypertensives.

Anxiolytics

Anxiolytic is a term applied to all medications that act on the brain, and make the patient less nervous and anxious. Examples of Anxiolytics include Diazepam, Alprazolam and citalopram. These drugs are effective in cases where excessive sweating is caused by anxiety, fear or nervousness.

Beta blockers

Along with Anxiolytics, patients with anxiety may also find beta-blockers useful for stress-induced hyperhidrosis. Beta-blockers block adrenaline and other substances that make us anxious, thus making us less likely to sweat. Unlike Anxiolytics, they act on the nerve system and not the brain, and are not needed to be taken regularly.

Antihypertensives

Antihypertensives are a class of drugs that are used to treat hypertension. However it has also been found effective at treating hyperhidrosis. Clonidine, a type of Antihypertensive, reduces stimulation of the nerves which enable sweating, thus reducing the volume of sweat.

Anti-cholinergics

Anti-chlorinergics drugs are usually prescribed for a wide range of other conditions, such as urinary difficulties or an overactive bladder. Long term use of Anti-cholinergics is not recommended for hyperhidrosis due to potentially extreme side effects. Some of the compounds under this category include Robinul (Glycopyrromium Bromide), Oxybutynin (Ditropan), Pro-Banthine (Propantheline Bromide)

Iontophoresis

What is Iontophoresis

Iontophoresis is one of the hyperhidrosis treatment that has gained much popularity in recent years. In short, Iontophoresis is a drug delivery technique that uses a small electric charge to deliver the drug through the skin – almost like an injection, but without a needle. For hyperhidrosis treatment, Iontophoresis is done using tap water (i.e. no medicine is involved) and an electrical current is used to introduce ions into the body through sweat-glands. The mechanism of treatment of hyperhidrosis through Iontophoresis is not well understood but is thought to somehow involve the obstruction of the mechanism causing sweat to flow from eccrine ducts, thus reducing the generation of sweat from the treated body part. This treatment requires regular application as epidermal renewal leads to return of sweat production after some time.

Due to anatomical and functional constraints, Iontophoresis is most effective for palmar and plantar hyperhidrosis (excessive sweat in hands and in feet). Off-late, manufacturers have also come up with devices to treat other body parts such as face and underarms through Iontophoresis.

Iontophoresis Devices

Iontophoresis is administered through specialized medical devices. The Iontophoresis device, at its core is simply an electrical circuit that passes current through the part of body that is placed in the trays filled with tap water, and has 3 basic components:

• A source of electric current
• Trays to immerse the hand/feet into tap water and
• Wires to connect the current source to the tray.

RA Fischer, Drionic, Hidrex and Idromed are some of the popular manufacturers of Iontophoresis devices for hyperhidrosis. These machines are relatively similar, but can have considerable differences in terms of the ease of usage, control options, current type, current source type etc. The devices range upwards of $400 with more expensive ones costing much more. You can also make a basic Iontophoresis machine at home ( instructions).

 Is Iontophoresis Effective?

It is not entirely understood how Iontophoresis treats hyperhidrosis. As a result, you will get very polar comments and often unsubstantiated claims on internet (the manufacturers of the device claim that Iontophoresis is “proven” to be effective for hyperhidrosis, some others claim that it does not work).

However, as with most such things, the truth is somewhere in between. There is a lot of anecdotal evidence that Iontophoresis is an effective hyperhidrosis treatment (including the author), and a large number of patients have claimed to see effective, long lasting results for their hyperhidrosis condition through Iontophoresis. Over the course of last few years of my attempt to know more about hyperhidrosis and taking to a large number of patients through this website, I personally believe that this treatment option, if done properly, works for most of the people and at-least one research suggests that Iontophoresis may be effective in 80% of the cases.

Another consideration – no serious adverse effects have been ascribed to the Iontophoresis. So it may be worth trying if you have not already done that. There is very little to lose and a lot to gain.

How Iontophoresis is done?

At the most basic, this is how Iontophoresis works:

1. Mild electrical currents are produced using a battery or electric outlet.
2. The current is passed down cables to the treatment electrodes which are placed into trays filled with tap water
3. Hands and/or feet are then placed into the trays, completing the circuit and allowing current to flow into the skin
4. The affected area is left immersed for about 10-15 minutes
5. The frequency of treatment is more in the beginning till the symptoms come under control. Once you have relief from sweaty palms/feet, the frequency can be lowered to maintain the same (e.g. once every week)
6. Treating other areas of the body employs the same process, except that electrodes are covered by absorbent sponges soaked in tap water and placed onto the treatment area

The treatment can be easily performed at home unaided.

Iontophoresis Side Effects

Iontophoresis is generally considered safe, and side effects are generally limited to mild “pins and needles” tingling and mild reddening of skin. In very few cases, painful stinging, itching, small vesicles and mild shocks can also occur. For most people, the initial few sessions are mildly discomforting, but not painful. A lot depends on the Iontophoresis machine being used and the type of current – pulsed current generally results in less irritation as compared to direct current. Also, application of a jelly based product on any exposed cut/rash on the skin of the area being treated can significantly reduce the discomfort.

Who should not do Iontophoresis?

While Iontophoresis has minimal side effect and is in general suitable for most people, you should always get a qualified physician’s advice before starting this treatment. Specifically, the following categories of patients should not undergo Iontophoresis:

• Pregnant women
• Patients with cardiac pacemaker
• Patients with epilepsy
• Patients with cancer
• Patients with swollen, broken, or inflamed skin on the areas to be treated
• Patients with metal implants in the path of the current (orthodontic braces are generally considered safe)

MiraDry

MiraDry is the new kid on the block (relatively speaking) for Hyperhidrosis treatment. It is the trademark name of a non-invasive microwave-based technology for the treatment of underarm (axillary) hyperhidrosis. It was developed by Miramar Labs in 2006 and got FDA clearance 2011. Currently, this procedure is available only for underarm hyperhidrosis and does not treat hyperhidrosis for hands or feet

How MiraDry Works

While the technical details are complex, at the most basic level MiraDry treats excessive sweat by directing a pulse of high energy microwaves to the sweat glands – generating heat that destroys the sweat glands in the underarm area, thus curing the person of underarm hyperhidrosis.

In parallel, a continuous cooling system protects the outer layer of the skin while heat continues to spread into the region where sweat glands reside, resulting in cellular thermolysis. Sweat glands do not regenerate, so once destroyed, the excess sweat glands are expected to be permanently disabled.

How MiraDry is used

• Outpatient physician visits for MiraDry treatment typically take one hour during which a physician administers local anesthesia (usually lidocaine injections
• Then he/she uses the MiraDry handheld device to deliver electromagnetic energy non-invasively to the underarms.
• The MiraDry device cools the outer layer of the skin and patients usually experience little to no discomfort during the procedure.
• There is minimal to no downtime afterwards. Most patients are able to return to normal activities or work right after the procedure, and can typically resume exercise within several days.
• A mild over-the-counter pain medication and ice packs are generally recommended for a few days
• For some cases, it may require up to two procedures to fully destroy the sweat glands in the area.

Side Effects

Common side effects of MiraDry include

• Mild to moderate temporary swelling and discomfort in the treatment area (generally lasting about one week)
• Mild numbness or altered sensation of the skin in the underarm area (can last several months)
• In rare cases, it has been reported that the process may destroy other nerve cells in the area causing numbness in the arms and fingers
• Note that his process is relatively new, so the full extent of side effects or long term effectiveness is not known. Good news, however, is that compensatory sweating (sweating on other body parts, common after ETS surgery) has not been shown to be a concern.

MiraDry Cost

The cost of the procedure depends on the provider, facilities and the location, but it broadly range between $1,500 – $4,000 for a single session (you may require up to 2 sessions)

Botox

You have probably heard of Botox referring to cosmetic surgery (face-lift etc) – however, Botox injection is also a recognized hyperhidrosis treatment procedure – especially for underarm region.

How Botox works

Botulinum toxin is a protein and is one of the most acutely lethal toxins known. Botox is one of the forms of botulinum toxin that is available for various cosmetic and medical procedures. It is a very popular substance used for cosmetic purposes (e.g. wrinkle removal, face lifts etc.).

Botox, when injected into the affected areas can control hyperhidrosis by temporarily blocking the chemical signals from the nerves that stimulate the sweat glands. When the sweat glands don’t receive chemical signals, the severe sweating stops in the treated area. The other areas of the body are not affected and continue to sweat as before. The effect is temporary and lasts about 6 – 8 months after which the treatment is needed again to maintain the effects.

How Botox is used

Botox is administered beneath the skin through injections. The doctor may follow the following steps:

• Perform Iodine Starch Test: This step identifies the area responsible for hyperhidrosis. Doctor will paint the underarm are with iodine solution. After it dries up, she will lightly sprinkle the area with starch powder. The hyperhidrotic area will develop a deep blue-black color in about 10 minutes
• Prepare treatment area: The doctor will circle the affected area with a surgical marker, and then clean area inside circle with alcohol.
• Map area for injection: Using a surgical pen and standard ruler, the doctor will mark injection points about 1.5 to 2 cm apart.
• Inject BOTOX® product: The doctor will then count the injection points and allocate recommended dosage of BOTOX solution per injection, based on 50 Units per axilla. Then she will inject to a depth of about 2 mm. After injection, clean treated area with alcohol.

Side effects

BOTOX® can cause serious side effects including:

• dry mouth,
• discomfort or pain at the injection site,
• tiredness,
• headache,
• neck pain,
• Eye problems: double vision, blurred vision, decreased eyesight, drooping eyelids, swelling of your eyelids, and dry eyes.
• In some cases, the patient may get an allergic reaction. This may itching, rash, red itchy welts, wheezing, asthma symptoms, or dizziness or feeling faint.

BOTOX® is approved by the FDA to treat the symptoms of severe underarm sweating when medicines used on the skin (topical) do not work well enough.

Endoscopic thoracic sympathectomy (ETS)

ETS is the most publicized treatment option for Hyperhidrosis (especially Palmar Hyperhidrosis), and the one that earns the most money to the medical professional community! However, this is the most invasive hyperhidrosis treatment option, and should be considered as a last resort because it can (and frequently does) causes serious, irreversible side effects including compensatory sweating (excessive sweating on large areas of the body or all over), hypotension, arrhythmia, and heat intolerance.

While internet search may give a different impression, ETS should not be the first option to be considered for treating hyperhidrosis because of the potentially serious negative side effects of the procedure.

How Surgery for Hyperhidrosis Work

In simple terms – the ETS process blocks the transmission of nerve signals (from sympathetic nerve system) from the spinal column to the sweat glands and to thus prevent these nerve signals from “turning on” the sweat glands.

The procedure is performed with the patient under general anesthesia. A miniature camera is inserted into the chest under the armpit. The surgeons then cut or destroy the nerve paths associated with the overactive sweat glands – this requires collapsing of the lungs on both sides one by one.

Side Effects of Surgery for Hyperhidrosis (ETS)

The most frequently complained drawback of ETS surgery is compensatory sweating – i.e. sweating more than before in a different part of the body – this happens almost invariably, though the degree to which compensatory sweating occurs may vary patient to patient. Compensatory sweating is excessive sweating that occurs on the back, chest, abdomen, legs, face, and/or buttocks as a result of ETS surgery. It can be equally or even more extreme than the original sweating problem.

Other side effects of ETS include:

• Reduction in heart rate: While for the majority of patients this is of no consequence, patients who have an abnormally low heart rate or problem with their heart’s electrical conduction system may be severely affected. Patients that are highly competitive athletes that may require compensatory increase in heart rate or vascular tone with exercise are also impacted.
• Gustatory sweating – Patients who develop this problem note increased sweating when they are eating. This occurs in approximately 1% of patients
• Horner’s syndrome – When this occurs, the patient notes three findings on the side of the face where the stellate ganglion was injured. These include a slight drop in the eyelid, a small or narrow pupil, and the lack of sweating on that side of the face.

Surgery for Hyperhidrosis (ETS) – Key Considerations

The ETS process is generally irreversible, and comes with non-trivial risks of side effects. This should be considered as the last resort, and even then, the potential benefits need to be weighted carefully against the potential side effect. There are several other safer options available that may work for most of the patients and those should be evaluated first before considering surgery.

Local Underarm Surgery

Besides ETS discussed above, there is an alternate, less risky surgical options for patients with underarm hyperhidrosis. The local surgery works by removing/incapacitating the sweat glands in the underarm region so that they cannot produce sweat anymore.

How Local Underarm Surgery Works?

This hyperhidrosis treatment process requires sweat glands to be localized in a relatively small area – making underarm region the perfect candidate. The local surgery is not yet done for Palmar, Plantar, Facial or Truncal hyperhidrosis as the sweat glands in these areas are well distributed, making the task of removing them much more difficult.

There are multiple variations in the technique the surgeon can use to disable the sweat gland in the underarm region – including curettage, excision, liposuction, and laser or a combination of them. The procedure does not usually require generalized anesthesia. The result of a successful surgery is often a permanent relief from excessive sweat from the underarm region.

Side Effects

The sweat gland removal surgery is generally a safe treatment for underarm hyperhidrosis. However a lot depends on the specific technique used for the surgery, and the experience of the surgeon in identifying the sweat glands and disabling/destroying them effectively.

It should be note that using Laser for destroying sweat glands, while promising, is relatively recent and the long-term outcome and side effects of this technique are not well understood. Also, excision (i.e. complete removal of sweat glands) may result in severe complications (e.g. inability to move arm) and should thus be avoided in favor of other techniques.

The major side effect of ETS surgery – i.e. compensatory sweating is usually not a side effect of local underarm surgery. Just like other surgeries, there is always the risk of infection if the skin opening is not properly protected. Also, the patients may have temporary pain and bruising at the surgery site. The surgery also results in minor scars at the site of the surgery.

Local Underarm Surgery: Considerations

If you are considering Local Underarm Surgery for Axillary Hyperhidrosis treatment, ensure that the surgeon is experienced and have delivered good results in the past. While the above section may have made the surgery seem like a simple one (find sweat glands, destroy them, done), it is far from that. Spotting the sweat glands and destroying them is a highly skilled job and the results are highly variable from surgeon to surgeon. If the first surgery does not provide the intended reduction in sweating, your doctor may recommend a second surgery to take out the remaining sweat glands that were missed the first time.

Alternative Treatments

And then there are multitudes of “alternative” hyperhidrosis treatment options. While the scientific evidence around these options is thin, there are reasonable anecdotal evidences to think of these as something to explore if you have tried other options and they did not work for you (or if you don't want to try the other options for some reason).

Diet Control

Diet control treatment works on the principal that certain foods can increase the sympathetic nerve sensitivity and if the consumption of such foods is ceased, the nerve activity will reduce, thus reducing the amount of sweat produced.

It is not scientifically studied or proven, but the decrease in consumption of following foods has been reported to result in decrease of excessive sweat condition:

• Alcohol: When you drink a glass of alcohol, your blood vessels widen, according to the University of Wisconsin's Center for Alcohol Studies and Education. Although this will c\ause your body to lose heat in the long run, initially it may cause you to sweat.
• Cigarettes
• Caffeine: Caffeine is a stimulant that causes your heart to beat faster and raises your metabolic rate. When your metabolic rate increases, your body burns more calories, which in turn raises your temperature and makes you sweat. Hot coffee and tea can make you sweat even more simply because the temperature of the beverage is hot.
• Certain drugs
• Certain foods: Pepper, spices

Herbs

Natural supplements have long been used to help treat excessive sweating. These supplements are commonly used in treating hyperthyroidism, or overactive thyroid — one of the leading causes of excessive perspiration. Other beneficial supplements may include sage, witch hazel and eucalyptus.

Sage may be one of the most commonly used natural supplements in treating excessive sweating. Sage may be helpful in treating several conditions associated with excessive perspiration, including night sweats and menopause-related hot flashes. Sage is a powerful astringent, which means that it has the ability to cause tissue contraction, including contraction of your skin.

More scientific evidence may be needed to better understand the safety and effectiveness of these supplements for this health purpose.

Acupuncture

Acupuncture is an ancient Chinese medicine system that involves stimulation of specific points along the skin of the body using penetration by thin needles. According to this medicine system, stimulating specific points corrects imbalances in the flow of qi through channels known as meridians. It should be noted that Acupuncture, while a relatively well known medicine system, is not based upon western scientific knowledge.

Acupuncture can be beneficial by balancing overstimulated nerves and prevent them from being overactive, thus reducing sweating. Typically patients take about 8-10 acupuncture sessions which are sometimes combined with intake of herbs in pill format or granular or powdered teas ingested once daily.