Hyperhidrosis And The Distressing Problem Of Excessive Sweating
Hyperhydrosis is a condition that involves excessive sweating from the underarms, the palms, the soles of the feet or the face and head. Patients frequently complain that the appearance of soaked underarms is a major source of embarrassment. Many patients also lament how sweaty palms also can give the appearance of extreme anxiety. It is not uncommon for patients to complain that their professional and social lives have been disrupted by this condition. The majority of patients have suffered for years prior to seeking help for their condition.
The primary function of sweat secretion is to assist in regulating body temperature. Sweat glands are distributed throughout the body, but are more concentrated in the underarms, palms and soles of the feet. Most cases of hyperhidrosis have no detectable cause and can affect up to 1% of the population. Affected individuals appear to have an elevated baseline level of sweat secretion and an exaggerated response to other normal stimuli.
The overall goal of treatment is to reduce the volume of sweat secreted to a level that does not cause anxiety and embarrassment. The ideal treatment should be safe, effective and relatively inexpensive. Conservative treatments include prescription antiperspirants, oral medications, and iontophoresis. Prescription strength antiperspirants are effective for many patients, but drawbacks include the short duration of effect, skin irritation, and some agents can stain the skin. Anticholinergic medications have many side effects including dry mouth, blurred vision, urinary retention, and constipation. Both antianxiety and antidepressant medications have been useful in helping patients deal with hyperhidrosis. However, they are only useful for short periods, can cause dependency, and are associated with lethargy and drowsiness. Iontophoresis uses a battery powered device to provide direct current to the hands and feet while they are submerged in water. The treatments only block secretion temporarily, can be uncomfortable, sometimes cause skin irritation, and require maintenance therapy.
For many physicians Botox® injections have become the treatment of choice. Botulinum toxin is a protein produced by the bacteria clostridium botulinum. Currently it is used to treat a variey of functional and aesthetic conditions. It is most useful in focal areas of hyperhidrosis, such as the underarms. The treatment requires multiple small injections to the affected area. Injections are appropriately spaced 1-2cm apart and typically 50 units is adequate for one axilla or one palm. Some studies have shown patients can expect a 70 to 80 percent reduction of sweat excretion in the axillae and 26 to 31 percent in the palms. The duration of effect varies from 3-8 months depending on the patient and the dose used. Complications are minor for the most part and include: bleeding, numbness, and inadequate reduction in sweat secretion. In addition, decreased grip strength can occur with injections to the palms. The only real major drawback of this treatment is the discomfort experienced when treating the palms and soles of the feet. Generally, treatments of the axillae tend to be well tolerated.
Surgical treatment is reserved for the more aggressive forms of hyperhidrosis that remain unresponsive to conservative therapy. In the past, underarm skin and fat was directly excised to remove overactive sweat glands. Another surgical technique that has been advocated is liposuction of the underarm region. This method appears to disrupt the nerve supply to the sweat glands, but because it has not been widely used, its efficacy is unknown. Currently, the surgical procedure of choice in these most severe presentations of hyperhidrosis is thoracoscopic sympathectomy which directly disrupts the nerves supplying the sweat glands of the palm and the underarms. This minimally invasive procedure utilizes small incisions on the chest wall and an endoscope to gain access to the portion of the chest cavity where the nerves are located. General anesthesia and an overnight stay in the hospital are necessary. Patients can typically return to their normal behavior within a few days. Success rates are high for palmar hyperhidrosis, but tend to much lower for hyperhidrosis involving the underarms. Complications, although rare, can be quite serious and even life threatening. Side effects include compensatory sweating in up to 50 percent of patients, gustatory sweating in up to 1/3 of patients and permanent changes to the palmer skin.
In conclusion, hyperhidrosis can be very distressing, but fortunately there are a number of safe and effective treatments from many which most patients can benefit.