Hyperhidrosis: how can we improve the quality of life for those who suffer from excessive sweating?
Julie Halford RGN, Specialist nurse, founder member of and medical adviser to the Hyperhidrosis Support Group
Julie Halford is a specialist nurse who works in eight hospitals across Hampshire, Oxfordshire & Buckinghamshire. She set up the UK Hyperhidrosis Support Group 12 years ago; this is an on-line support group for patients and medical staff, run voluntarily. It has 12000 members - Julie advises patients and medical staff on some of the most helpful treatments for hyperhidrosis. She also provides hyperhidrosis training sessions and study days for medical staff throughout the UK, and is a regular speaker at medical conferences.
All information here is from the authors 15 years of knowledge and experience working with Hyperhidrosis patients & dermatology staff throughout the UK
What is Hyperhidrosis?
Primary or focal hyperhidrosis is a chronic idiopathic disease characterised by perspiration in excess of the physiological amount necessary to maintain thermal homeostasis. It affects both sexes equally, and all races in at least 1% of the population. Any part of the body may be affected, such as the face, head, neck, back or groin, but most commonly the hands, feet and axillae are the primary concern.
Hyperhidrosis generally presents before the age of 25; it is often present in young children, but becomes more apparent in adolescence. This socially unacceptable condition of excessive sweating and the inability at times to even carry out simple tasks such as dealing with paper, keyboards, mobile phones, racquet sports, musical instruments, metal and electrics, make a miserable existence for those who suffer with hyperhidrosis. However, with treatment, quality of life is improved immensely and there is much that can be done to help people.
Hyperhidrosis is linked to over activity of the parasympathetic nervous system. Specifically, it is the thoracic sympathetic ganglion chain. This chain controls the eccrine glands, responsible for perspiration throughout the entire body and, when it is over-active, causes excessive sweating at most times during the day. So, if a patient presents with night time sweating, then the diagnosis is not primary hyperhidrosis.
Secondary hyperhidrosis may be caused by
- infection
- heart disease
- malignancy
- diabetes
- hyperthyroidism
- Parkinsons
- spinal cord injury
- menopause
- obesity
It is common for secondary hyperhidrosis to be caused by medication. There are over 300 reported drugs responsible for excessive sweating; in particular, antipsychotics, selective serotonin reuptake inhibitors (SSRIs) and progestogens. Drugs such as cannabis can also be implicated [1].
Initial advice in primary care
- try aluminium chloride antiperspirants such as Anhydrol, Forte, or Driclor applied at night to dry skin. These are available on prescription and over the counter. However, these strong antiperspirants often cause irritation [2] and are generally only suitable for mild axillary hyperhidrosis. We suggest using Sweatstop - http://www.sweatstop.co.uk , as it contains aloe vera, which is much kinder to the skin and is available in a variety of strengths. We have trialled these products on our members and have received very positive feedback. However, Sweatstop is not available on prescription
- if aluminium chloride antiperspirants fail to get results, secondary referral should be considered. However, if the patient suffers from generalised hyperhidrosis or compensatory sweating following endoscopic thoracic sympathectomy (ETS), then anticholingergic drugs should be considered. Modified release Oxybutynin (Lyrinel XL 10mg) (POM) should be considered, although the non-slow release version has also been successful in many cases, albeit with side effects
- Pro-banthine (POM) is licenced for hyperhidrosis, but again, can often invite unwanted side effects
- use emollient washes and moisturisers rather than soap based products
- avoid tight clothing and man-made fabrics
- wear leather shoes, cotton or absorbent socks specifically designed for excessive sweating
- introduce to patient support group – http://www.hyperhidrosisuk.org
Secondary referral
Treatments
Iontophoresis
Iontophoresis is the 2nd line of treatment for primary hyperhidrosis of the hands, feet & axillae. In most cases, it significantly reduces sweating in the treated limb [3]. In the United Kingdom, iontophoresis is widely practised in most dermatology departments, a few podiatry clinics, physiotherapy and vascular departments, and in some General Practitioner (GP) surgeries.
The affected area is placed into water (or a damp pad applied in to the axilla), and a weak current is passed through the water/pad. The current is thought to help block the sweat glands. The treatment is not painful but the electric current can cause some mild, short-lived discomfort and skin irritation [4]. An initial seven treatments are given over a four-week period; nationally, this protocol results in complete cessation of hand/feet sweating in 85% of cases, and approximately 70% of those with axilla sweating [5].
It is a safe treatment and can be undertaken at home; home machines are generally safe to use, providing they are bought from a reputable company, such as Idrostar (http://www.iontophoresis.info), as these machines use re-chargeable batteries, and are safe, effective and are portable. For children we suggest a pulsed current machine such as the Idrostar +.
Contraindications
- cardiac pacemakers & cardiac arrhythmias
- metal orthopaedic implants in line with current flow (small metal pins are fine)
- pregnancy
- peripheral neuropathy
Botox
Botox (botulinum toxin A) works by interfering with the effect of neuro-transmitters and paralysing the sympathetic nerves. It is a temporary treatment that has to be repeated two or three times a year 6. It is generally successful, but can on occasion, have undesirable side effects.
It is only suitable and licensed for treatment of axillary hyperhidrosis and is often not available on the NHS. Sessions at a private clinic cost between £300 - £600 per session.
Axillae Surgery
Retrodermal curettage, axillae aspiration, sub-dermal liposcution, or Vaser & Shelly’s procedure can be performed for hyperhidrosis of the axillae, as can Laser Sweat Ablation http://www.lasersweatablation.co.uk. Generally, these procedures are not performed on the NHS. However, a list of practitioners can be found at http://info@hyperhidrosisuk.org
Hand Surgery
In the past, ETS was the secondary treatment of choice. However, it could cause severe compensatory sweating, making the patient’s life quite unbearable. The National Institute for Health and Care Excellence (NICE) guidelines have recently been revised, and it is now recommended that this surgery should not be considered unless all other treatments have failed.
Patient information leaflets are available on request from Julie at the Hyperhidrosis support group: http://info@hyperhidrosisuk.org