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No sweat: effectively treating hyperhidrosis

Julie Halford
RGN
Specialist Adviser to the Hyperhidrosis Support Group
E:info@hyperhidrosisuk.org
T:07831 166081
F:01264 736061

Hyperhidrosis is a condition that affects approximately half a million people in the UK and can have immense social and psychological effects on the sufferer. This in turn can lead to withdrawal from society, often causing the person affected to become depressed or reclusive.
Primary hyperhidrosis is a result of sympathetic hyperactivity of the eccrine sweat glands, usually in the hands (palmar), feet (plantar) or axillae (axillary). However, hyperhidrosis may affect almost any area of the body, including the face, head, chest and back.
A further aspect of excessive sweating is known as gustatory sweating. This is an outbreak of excessive sweating when confronted with the smell or taste of certain foods and alcohol.
It is thought that about half of all sufferers have a genetic tendency towards excessive sweating, and most of these have at least one parent with the condition.
Sweating excessively all year round often has a negative effect on a patient's life. Wetness and staining of clothes, sodden and smelly shoes, inability to grip objects such as pens, cold and wet handshake, damage to keyboards and difficulty dealing with paper and metals - all can make for a miserable existence for the sufferer.(1)
However, recently treatments have become available to help patients with this embarrassing condition, and most people can now lead normal lives. Treatments are available throughout the country, and a good source of information and individual help is available through the Hyperhidrosis Support Group, which was set up for patients and medical staff. Patient literature for general practices is also available on request.
Sometimes people will sweat excessively because of other causes, such as hyperthyroidism, malignant disease, psychiatric disorders, menopause and obesity.(2)
On examination, it is important to distinguish between generalised hyperhidrosis, where the entire skin surface is affected, and focal, where only certain areas are affected. If generalised, it is necessary to perform routine screens such as full blood count (FBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), urea and electrolytes, random blood sugar (RBS), thyroid function tests (TFTs) and further screens if clinically indicated, such as liver function tests (LTFs), blood film for malarial parasites, and HIV.

Treatment
Initial treatment should be carried out in primary care using simple topical preparations of aluminium chloride hexahydrate products, such as Anhydrol Forte or Driclor, for all sites of hyperhidrosis. However, irritation of the skin is common, and these products should be used with caution and intermittently when this occurs. They are generally more successful in the axillae than any other area.
These products should be applied at night to a clean, dry skin and washed off the following morning. The area should not be shaved for 24 hours before and after use. Follow-up after two months is recommended, and secondary referral will be necessary if the sweating has not been controlled.(3)

Iontophoresis treatment 
Iontophoresis, or electrical stimulation, is the single most effective treatment for palmar and plantar hyperhidrosis, and trials are being undertaken for treatment of the axillae, though it will be some time before the results become available.
Hands and/or feet are placed in plastic baths that are filled with water, and the current is turned on. This is totally pain-free, and the user experiences only a "pins and needles" sensation (see Fig 1).

[[NIP25_fig1_22]]

It is not fully understood how iontophoresis works, but the treatment is painless and noninvasive and there are no reported side-effects, making long-term treatment possible. One school of thought suggests that a parakeratotic plug is formed, blocking the duct without damaging the sweat gland.(4)
Iontophoresis treatment is now mostly performed in dermatology departments but also in some physiotherapy departments. However, iontophoresis treatment can be carried out in general practice as it is simple, pain-free, safe, cheap to run and easy to administer.
Nearly all patients achieve a complete cessation of sweating using just tap water, and those who do not can add an anticholinergic drug such as glycopyrronium bromide (eg, Robinul) to the bath to achieve a successful result. Patients then undergo further treatment as and when necessary. This treatment can be practised at home using their own machine, which they can purchase at a reasonable cost. Iontophoresis requires consent from the patient, and consent forms are available from Julie Halford.

Botulinum toxin A
"Botox", as it has become widely known, is now licensed in the UK to treat axillary hyperhidrosis only. The treatment consists of a series of injections intradermally into the axillae. The results to date have proven to be successful in most cases, but treatment is not permanent and is required every 4-8 months. In many hospitals this treatment is not available on the NHS, and treatment can be expensive if done privately.

Drugs
An anticholinergic drug such as glycopyrronium bromide can be administered up to three times a day. This drug was manufactured in the UK and licensed as an antispasmodic, however, it is now available only from the USAs on a named-patient basis.
Many dermatologists are happy to prescribe this for their patients if necessary, but there seem to be very few GPs who are prepared to, due to the cost of the drug. Antimuscarinics such as oxybutynin can be helpful, especially for those with hyperhidrosis of other areas such as the face, head, chest and back. However, their side-effects may limit their use, dry mouth being the most common problem, though younger patients tend to tolerate these well as they feel their condition is ruining their lives.

Surgery

Endoscopic thoracic sympathectomy (ETS)
In order to treat hyperhidrosis, the surgeon must divide the overactive sympathetic nerves that cause the excessive perspiration. These nerves lie along the sympathetic nerve chain, which runs alongside the spinal column. The surgery involves a general anaesthetic, deflation of one of the lungs and insertion of a trocar and laparoscope into the axillae to access the sympathetic ganglion chain where the nerves are to be cut and cauterised. This procedure is then carried out on the other side of the body.
However, it must be noted that the side-effects can sometimes be severe, and compensatory sweating is common; so surgery tends to be performed only if other treatments have been unsuccessful.

Subcutaneous sweat gland curettage
This surgery can be performed under local anaesthetic as an outpatient procedure, and patients can return home immediately after the surgery and usually return to work the next day.
A small incision is made in the axillae, and surgical excision of the axillary tissue is carried out. Antibiotic ointment is introduced into the puncture wound, which is not sutured, and a wad of gauze is taped into the axillae. Sweating ceases at once, and as early as 4-6 weeks the puncture incisions are almost invisible. By 4-6 months postoperatively, physiological sweating returns, but in most cases the hyperhidrosis does not return.
The Hyperhidrosis Support Group has very few listings of specialists who perform this surgery. If you have, or know of anyone who has, please contact the support group.

Disposable axillae pads
These disposable pads are useful for anyone with axillary hyperhidrosis and can be worn under all clothing. Generally patients buy their own, but some hospitals and practices also provide them.
If you would like further advice on which hospitals in the UK provide treatment for hyperhidrosis, or if you are interested in providing this service in your surgery or would like patient information, then please contact Julie Halford or contact the Hyperhidrosis Support Group.

References

  1. Tristram SJ. Treatment options for hyperhidrosis. GP 2005 Apr 22:47.
  2. Halford J. Hyperhidrosis, hospital, surgery and home treatments. Br J Dermatol Nurs 2004;8(2).
  3. Lowe N, Cliff S, Jones H, Halford J, Payne S, et al. Guidelines for the primary care treatment and referral of focal hyperhidrosis. Herts: Medendium Group Publishing; 2003.
  4. Hyperhidrosis Support Group. Iontophoresis questions and answers. Available from URL: http://www.hyperhidrosisuk.org/iontophoresis.htm

Resource
Hyperhidrosis Support Group
W:www.hyper hidrosisuk.org