12.07.2022

Hyperhidrosis: treating excessive sweating

Name: London Lip Clinic
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Excessive Sweating Treatment at our London Clinic

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EXCESSIVE SWEATING HYPERHIDROSIS

Sweating is an essential bodily function to regulate body temperature, and it can also occur during times of anxiety. However, if the sweating is excessive, ongoing and unnecessary, this is known as hyperhidrosis.

Forms of Excessive Sweating Hyperhidrosis

Hyperhidrosis can be classified by the area of the body affected (focal or generalised) and whether or not there is an underlying cause (primary or secondary).

Primary focal excessive sweating hyperhidrosis is the most common type. It usually affects the:

palms of the hands
soles of the feet
armpits (axillae).

Other areas, such as the face, scalp, back, neck, chest, groin, legs and buttocks – or a combination of these – can also be affected. It typically affects both sides of the body equally during waking hours and can occur in otherwise healthy individuals. While there is no known cause, there is some evidence of a genetic link, as a positive family history is reported in 30-50% of cases.

For affected individuals, the nerves that supply the sweat glands are often overactive due to stress or anxiety. This often occurs due to worrying about increased sweating, making the symptoms worse.

Secondary focal excessive sweating hyperhidrosis is much less common and has a specific cause, while still involving certain parts of the body. Causes include:

neurological issues, such as diabetic neuropathy (which may cause gustatory sweating – where the thought of food or chewing causes sweating on the forehead, face, scalp and neck instead of salivation), peripheral neuropathy, stroke, or spinal cord lesions and tumours
cancer
Raynaud’s phenomenon
rheumatoid arthritis.

Generalised excessive sweating hyperhidrosis affects the whole body and is usually secondary to an underlying cause, such as:

anxiety
cardiovascular problems – heart failure or endocarditis
endocrine issues, including hyperthyroidism, diabetes, hyperpituitarism, obesity and gout
infections eg tuberculosis, HIV and malaria
neurological issues, such as Parkinson’s and epilepsy
pregnancy or menopause
medication, including:
- aciclovir
- antidepressants (selective serotonin reuptake inhibitors (SSRIs), venlafaxine, duloxetine, tricyclic antidepressants, trazodone and mirtazapine)
- cholinesterase inhibitors (donepezil, rivastigmine)
- ciprofloxacin
- esomeprazole
- opioids
- pilocarpine
- propranolol
alcohol and illicit drug misuse or withdrawal.

How common is hyperhidrosis?

The prevalence of hyperhidrosis is not known, as many do not seek help for this condition. For those that do, pharmacists are in an ideal position to signpost them to advice and treatment.

The average age of onset of primary hyperhidrosis is between 14 and 25 years. This form of hyperhidrosis is uncommon in the elderly and the symptoms often decline with increasing age, suggesting it may be a self-limiting condition which improves in later years.

Symptoms of hyperhidrosis

Excessive sweating can have a significant impact on day-to-day life. Not only can it result in physical complications, but the embarrassment can impact on an individual’s mental health.

Sweaty or clammy palms can result in socially awkward situations, as affected individuals may avoid shaking hands, interacting with people or even starting relationships. In addition, it can often affect their work, their ability to drive or even simple tasks like using a smartphone.

Feet that are wet or clammy can feel cold or become slippery, causing sandals to slip off, and the sweat may damage shoes.

Copious underarm sweating, which can be seen through clothes, can also cause embarrassment. Students may be too embarrassed to put up their hands in class in case it reveals noticeable wet patches, which can affect their studies.

These symptoms can result in fungal or bacterial infections of the skin, while concern over social interactions may result in depression and low self-esteem. There is also the time spent washing sweaty areas and changing clothes, and worrying about body odour (bromhidrosis).

Other causes of excess sweating Hyperhidrosis

It’s important not to assume that hyperhidrosis is the only diagnosis. An underlying cause should be suspected and referred for further investigation if there:

is generalised sweating
is night-time sweating ie during sleep (as this suggests an infection – eg tuberculosis – or Hodgkin’s disease)
are symptoms and signs of systemic disease eg fever, weight loss, anorexia or palpitations
are prescribed drugs being taken that are known to cause sweating (see Generalised hyperhidrosis, above)
is unilateral or asymmetrical sweating (suggesting a neurological lesion or tumour, or an intrathoracic malignancy)
are symptoms or signs of any other cause of secondary focal hyperhidrosis or generalised hyperhidrosis
is an assessment as to whether anxiety may be an exacerbating factor.

Equally it is important to rule out a simple cause, such as heat or temperature of the room, or heavy clothing layers.

How is Excessive Sweating Hyperhidrosis diagnosed?

If a patient presents in your pharmacy with excessive sweating, it is important to establish if they have already been diagnosed by a doctor, to rule out any serious underlying causes.

The initial assessment will require a thorough history taking to determine:

the age of onset
any family history of excessive sweating
the location, distribution and symmetry of the sweating
how often it occurs
the time of day and duration of the episodes
any current medication or drug misuse
any other medical conditions
the impact on quality of life.

It is important to identify any associated symptoms, for example:

increased temperature
weight loss
palpitations.

You should determine if the excessive sweating is caused by a trigger, such as: anxiety, stress, heat, exercise, smoking, alcohol, caffeine, chocolate, spicy or citrus food, hot food or sweets.

In addition, tests – for example, full blood count, liver function tests and body mass index – will help to rule out any other underlying cause.

Primary focal hyperhidrosis is diagnosed if the person has visible excessive sweating which:

occurs in at least one area of the following: palms, soles, armpits, face
has lasted six months
has no apparent cause
has at least two of the following:
- bilateral and symmetrical sweating
- sweating that hinders daily activities
- sweating that occurs at least once a week
- a positive family history
- onset began before 25 years of age
- local sweating ceases during sleep.

Primary focal hyperhidrosis is still a likely diagnosis if the symptoms have lasted for less than six months or onset is 25 years of age or above, but in these cases clinical judgement should be used to exclude an underlying cause.

How is excessive sweating hyperhidrosis treated?

Once the patient has a diagnosis, they can work in a stepwise approach to try and control their symptoms and discomfort. For example, if they have been diagnosed with generalised or secondary focal hyperhidrosis, then the underlying cause will require medical intervention and consequent treatment.

If they have primary focal hyperhidrosis, patients have many options available to them and this is where the pharmacist can intervene and provide advice, support and treatment.

OTC topical treatments

The primary product to control sweating is an antiperspirant. Unlike a deodorant, which merely masks the smell, an antiperspirant is an astringent which works to reduce sweat secretion. Individuals with hyperhidrosis will no doubt find that standard products are not effective for them and their formulation may not always be appropriate for the location of the sweating.

However, stronger antiperspirants are available to buy in the pharmacy. Aluminium chloride 20% solution is available as a general sale list (GSL) product, and examples include: Driclor (roll-on), Perspirex (roll-on or lotion) and Odaban (spray).

Alternatively, various forms in larger bottles are available as pharmacy (P) medicines, including Driclor and Anhydrol Forte. They can be supplied on prescription, but it may cheaper to buy over the counter than to pay the NHS prescription charge in England.

Patients should be advised to use roll-on versions for treatment of hyperhidrosis of the armpits, hands and feet. One or two “rolls” should be applied once at night-time to completely dry, unbroken skin. They should not be applied straight after bathing and should be left overnight to work on the sweat glands before being washed off the following morning.

You can advise patients that the frequency may be reduced to once or twice a week as the condition improves, but can return to daily application if the condition worsens.

Normal deodorant and perfume can be worn during the day, but patients should not shave for 24 hours before and after application of aluminium chloride products. You should make patients aware these products have the potential to discolour clothing and warn them to take care around open flames, as the products are flammable.

Odaban spray can be used all over the body, but only one or two sprays are required and the excess should be wiped away with a tissue. You should advise patients to only use it on problem areas. Some patients who have excessive sweating of the face may prefer to apply the product to a cotton pad and then to the face.

As aluminium chloride may cause skin irritation, you should consider if the patient has sensitive skin before recommending products containing this active ingredient. If irritation does occur then you can recommend soap substitutes, less frequent use of the product or hydrocortisone 1% cream for up to two weeks to reduce the irritation.

Prescribed oral treatments

Topical treatments may not always be effective or the areas may not be suitable for this treatment. Anticholinergics are the main form of oral treatment, although the side effects of dry mouth, constipation, urinary retention and blurred vision may not be tolerated by all.

Anticholinergics decrease sweat secretion by competitive inhibition of acetylcholine at the muscarinic receptors near eccrine sweat glands. Modified-release oxybutynin can be used, but this is an off-label indication. Propantheline bromide is licensed for use in gustatory sweating.

Prescribed topical treatments

Higher strength aluminium salts (up to 50%), and topical glutaraldehyde or formaldehyde are an option for those who do not respond to other treatments.

Specialist treatments and surgery for excessive sweating hyperhidrosis

Botox

Botox contains botulinum toxin type A complex and is licensed for intradermal use for severe hyperhidrosis of axillae unresponsive to topical antiperspirants or other treatments.

It acts by inhibiting acetylcholine release from the sympathetic cholinergic nerve terminals that supply sweat glands. The treatment can be painful, but the effects will typically last between six and nine months.

Iontophoresis

This process involves a machine passing a low voltage electrical current through the skin. It tends to be used on the hands or feet while they are immersed in shallow trays of water, but can also be used to treat the underarms, with the aid of electrodes. The mechanism of action is not completely understood, but it is found to be effective in about 70-80% of patients.

An improvement is normally noticed after six to 10 sessions, and this is maintained by further treatments at intervals of one to four weeks. Adverse effects include transient discomfort, erythema and vesicle formation at the treatment site.

National Institute for health and Care Excellence (Nice) guidelines state that glycopyrronium bromide can be added to tap water during iontophoresis if tap water alone has not worked; however, anticholinergic side effects such as those mentioned previously may be experienced.

Surgery

Surgery is only considered if other treatments have failed or are not tolerated. Local surgery, involving localised resection of eccrine sweat glands, can be successful for some. It is useful for small areas of axillary excessive sweating hyperhidrosis, but there is little research into its long-term efficacy.

Endoscopic thoracic sympathectomy (ETS) is a last resort carried out under general anaesthetic by a vascular surgeon. It involves division of the sympathetic chain over the neck of the ribs in the pleural cavity, with the aim of preventing transmission of nerve signals from the sympathetic ganglia to the nerve fibres producing the excessive sweating.

It is used as a permanent symptom relief solution in the case of severe hand, axillary and sometimes craniofacial hyperhidrosis. Unfortunately, after about six to 12 months, it can result in compensatory hyperhidrosis in other areas of the body; for example, the back or legs. Other complications can include gustatory sweating, pneumothorax, atelectasis and significant bleeding.

Alternative treatments to excessive sweating hyperhidrosis

Laser treatmentLaser therapy is an option, but there is limited research on the long-term efficacy of this treatment.

MiraDry

MiraDry is a permanent procedure and does not require surgery. It involves using a hand-held device to deliver electromagnetic energy (microwaves) to destroy sweat glands, and only requires one or two treatments.This procedure results in an average sweat reduction of 82% and is permanent – as the sweat glands do not grow back. It has been shown to be safe and effective, with clinical trials demonstrating that 90% of patients were satisfied with the sweat and odour reduction. Some practitioners are opting for this treatment over minor surgery, as a safe and effective way of providing permanent treatment.These alternative treatments will require private funding, as they are not recommended by Nice or provided by the NHS. See sweatsmart.co.uk for more information about treatment options in the UK.

General advice for excessive sweating hyperhidrosis includes:

wear loose-fitting, white or black clothing, to avoid the appearance of sweat marks
avoid tight clothing and man-made fibres such as nylon
wear layers that can be removed, to prevent overheating
change clothes frequently
use dress shields (also known as armpit or sweat shields) to absorb excess sweat and protect delicate or expensive clothing
use an antiperspirant rather than a deodorant
wear leather shoes and avoid heavy, occlusive footwear, such as boots and sports shoes
use absorbent insoles
use foot powder twice a day
wear moisture wicking socks and change these twice a day
alternate shoes to allow them to dry properly between use
visit a podiatrist to maintain healthy feet
avoid triggers that worsen sweating eg spicy foods and caffeine
use light talcum powder on the body – if there is no history of ovarian cancer – but avoid the genital area in women; take care if using it around babies, to avoid powder inhalation
consider treating any underlying anxiety with cognitive behavioural therapy
lose weight (if required).