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Everyone sweats to a certain extent. It is the body’s normal way to get rid of excess heat and control the temperature. Sweating is a common feature in most individuals who exercise, jog, run or do any excessive physical activity. However, there are some individuals who sweat despite having no physical activity. There is constant perspiration most commonly in the axilla or on the arms. This condition is called excessive sweating or hyperhidrosis. The hyperhidrosis occurs despite the absence of heat, stress or fever. Focal hyperhidrosis causes appreciable social problems in both private and professional life. Profuse sweating can result in skin maceration and secondary microbial infections Excessive sweating is classified as either localized or systemic. This is very important to know as the treatments are very different. Current treatments for axillary hyperhidrosis are often ineffective, short acting, or not well tolerated.
Focal excessive sweating (localized hyperhidrosis)In focal sweating, the excessive sweating occurs either in the palms, soles, axilla or face. It may occur on one or both sides of the body. The rest of the body acts normally and does not perspire. The most classic example of localized sweating is the axilla (armpit). Axillary Hyperhidrosis (Armpit Sweating) is associated with excessive dripping sweating in the armpits. If the clothes are not frequently changes, an odor is always present. The amount of sweating is extremely difficult to control and does not respond to any deodorants and anti perspirants. While the presence of axillary sweat and bromhidrosis (odor) is normal in most individuals after the age of puberty, some individuals experience excessive sweating that pours down the arms and soaks the clothes, creating a socially embarrassing situation. Because of the constant wetness and staining from the sweat, these poor individuals are not able to wear clothes of certain fabrics or colors. The condition when severe can lead to social isolation and depression. It is always worsened in the presence of anxiety and stress. Why localized seating occurs in one part of the body is not known and is not associated with any other disorders. It appears that the sweat glands in these areas become hypersensitive or overactive than normal. Frequently, this condition may run in families but no genetic linkage factor has been identified. The condition can develop at any age but most individuals complain about the sweating in their late teens. Both men and women appear to be equally affected. The condition does vary in severity with time. It is silent for some time and then starts up again. The sweating is usually worsened by stress, emotional lability spicy foods and heat. The sweating is always made worse by anxiety. In most cases the triggers of sweating remain unknown. The majority of individuals who develop this disorder are under the age of 25. The condition appears to occur in 3 out 100 people. It is a long term condition, however, a significant number of individuals to improve with time.
Diagnosis There are no tests to make a diagnosis of localized sweating. The diagnosis is made by examining the patient, the major complaint by all individual is that anti perspirants just failed to work.
Generalized excessive sweating (generalized hyperhidrosis)In generalized sweating, the individual continues to perspire all over the body. This condition is less common than the localized version but it is related to other medical conditions. Anxiety, infections fever, hyperthyroidism, infection of the heart valves, drugs and some cancers can all cause this disorder. In this condition, blood work is required and the physician makes an attempt to find the underlying disorder which is responsible causing the sweating. The treatment depends on the cause of the disorder.
What are the possible complications of focal excess sweating?Although sweating is not life threatening, it is distressing and causes a lot of social embarrassing. The majority of the individuals with palmar sweating find that anything they hold in their hands gets soaked and they are afraid to shake hands because of the excessive wetness. The condition can be severe enough to lead to social isolation and avoidance of contact with people. The constant wetness can occasionally cause maceration and redness of the skin. Others may develop severe itching around the area.
What are the treatment options for focal excessive sweating?Therapy can be challenging for both the patient and the physician. Both topical and systemic medications have been used. Other treatment options include Iontophoresis and Botulinum toxin injections.
General care For mild sweating which is localized the following may help: - use soaps which are bland and contain an emollient - avoid spicy foods - avoid heat - Use anti perspirants regularly for the axilla (Antiperspirants reduce the release of sweat, deodorants mask any unpleasant smell) - Avoid clothes that more easily show up sweat marks. - Wear loose clothing under the armpits, and preferably not made with man-made fibers such as lycra and nylon - Change socks at least twice daily - Use an absorbent foot powder twice daily - Wear a different pair of shoes on alternate days, to allow them to dry fully. - Avoid running/sport shoes or boots, as these are likely to have an occlusive effect.
Deodorants and Anti perspirants In people with significant axillary sweat or odor problems, deodorants and antiperspirants often fail to control the sweat or odor. Ant cholinergic medication, such as Robinul, offer temporary relief and may cause total body dryness and drowsiness. Drysol also dries the skin and requires lengthy treatment, causing a temporary result. Oral medication such as Robinol offer temporary relief however it may create body dryness.
Topical medications Once upon a time topical agents were used to treat sweating disorders. Over the years numerous chemicals have become available and include topical anti cholinergics, boric acid, 2-5% tannic acid solutions, resorcinol, potassium permanganate, formaldehyde (which may cause sensitization, glutaraldehyde, methenamine. All the above chemicals are applied on to the dry skin at night. It is recommended that the skin be covered with a dry dressing. The results of these drugs are very variable. However, the major reason why all these drugs have fallen out of favor is the skin irritation they cause. In addition, the staining of the clothes is irreversible. Long term usage can cause cracking of the skin but without actually decreasing sweating. Maxum is another product on the market with a somewhat higher pH level, causing less irritation. Maxim can be purchased online. All drawbacks taken under consideration, lotions are the first step in attempting alternative methods to surgery. Today, the use of these chemical has been relegated to the history books.
Aluminum chloride - a strong antiperspirant If the above general methods do not help control the sweat and if the normal antiperspirants fail, one should try and get a prescription of an antiperspirant that contains aluminum chloride. Aluminum chloride is a ‘strong’ antiperspirant and is thought to act by blocking the sweat gland ducts. It tends to work best in the armpits. However, it may also work for sweating of the palms and soles. It is not recommended for use on the face because if the eye gets expose, it can cause a very painful irritation. Several brands of aluminum chloride anti perspirants are available (Driclor, Anhydrol Forte, ZeaSorb, Odaban). Some come in a bottle as roll on applicator, others are in a powder form and others come in a spray. These anti perspirants work best when applied to clean dry skin and should be applied at night (when the sweat glands are less active). For these anti perspirants to work well, one should: - apply the agent at bed time (sweat glands are less active at night) - Wash off the agent in the morning - Avoid shaving the area for at least 24 hrs - Avoid getting it in the eyes - do not apply on broken or inflamed skin or redden skin The agent should be applied every 24-48 hours until the sweat starts to decrease. Once the sweat decrease, the agent can be applied every 1-2 weeks. The response usually takes at least 1-3 weeks to become obvious. Once sweating is under control, the agent should only be applied once every 2-3 weeks. The problem with aluminum chloride antiperspirants is the severe skin irritation or inflammation. If this occurs and is tolerable, one may continue as it will decrease the sweating. To decrease the side effects of the anti perspirant, one needs to combine it with a topical corticosteroid.
Iontophoresis This is an old technique that uses electrical stimulation. It is used mainly to treat sweating of the palms and/or soles and rarely the armpit. Treatment involves putting the affected areas (usually hands and/or feet) into a small container filled with water. A small electrical current is then passed through the water through special electrodes from a nearby machine. It is not painful or dangerous, but may cause a sensation of 'pins and needles' feeling. How it works is unknown but does help block the glands from secreting sweat. Iontophoresis treatment are done 3-4 times per week and each session lasts about 30 minutes. Very few individuals claim improvement after 6-10 treatment sessions. A break of 2-4 weeks is allowed in between the sessions. Some recommend a maintenance treatment on a weekly basis. If ordinary tap water does not produce any results, a drug called gycopromium bromide is sometimes added to the water. This may improve the rate of success. However, Iontophoresis does not work for everyone and at best works for less than 3% of individuals. Today Iontophoresis is done in clinics, hospitals and portable devices also allow for home use. Iontophoresis is not recommended if one is pregnant or has a pacemaker, metal clips or pins in the body.
Botulinum toxin injectionsIn the last decade Botulinum toxin has become an option in the treatment of axillary sweating disorder. The treatment include injections of Botulinum toxin in the axilla. It acts by blocking the release of secretions from the sweat glands. Rarely it is used to treat sweating around the palms or the face. When used in the hand area, it is not only painful but may temporarily paralyze the small hands of the muscle. Botulinum is not a cure for sweating and its effects wear off after a period of 4-10 months. Numerous injections (20-50) of the toxin are usually required. The treatments have to be repeated every 6-10 months. After the injections most individuals complain of flu like syndrome, which lasts a few days.
Surgery The latest advances in surgery can help treat hyperhidrosis permanently. The surgery involves excising the sympathetic ganglia (T1-T4). A survey shows that thoracoscopic sympathectomy to be the best procedure in the treatment of sweating. It produces immediate results and improves the quality of one’s life. There many variations for thoracic sympathectomy and it is considered the gold standard in the treatment of this awful condition. Advances in surgery have allowed for this procedure to be done through 1 cm holes in the chest. The recovery is rapid and sweating stops the next day. The day after surgery, the majority of individual report no more sweating. After 3 years about 10-15% of patients do report some recurrence of sweating but this is tolerable. The individuals claim a significant improvement in life and no social embarrassment. Surgery complications include: - compensatory sweating (induction of sweating in previously unaffected areas of the body), - gustatory sweating (sweating during eating) - pneumothorax (air in the chest cavity) - intercostal neuralgia (pain on the chest wall) - Horner syndrome (sagging of the eye lid) - Recurrence of hyperhidrosis. Other Surgery techniques have also been developed but include destruction of the sweat glands. The results over a long time are unknown. Subcutaneous liposuction is another method of removing the sweat glands responsible for axillary sweating. Compared with classic surgical excision, this modality results in less disruption to the overlying skin, resulting in smaller surgical scars and a diminished area of hair loss.
Alternatives to surgery Some individual are not keen to undergo surgery and seek other ways to cure their sweating problem. Over the past 4 decades, numerous other methods have been developed to help treat sweating. While these are not main stream conventional medical therapies, they are available for those who are not keen for surgery. The methods include acupuncture, anti-anxiety medications, beta blockers, chelation therapy, purging of the colon with water, biofeedback, and herbal medicines. So far there is not an iota of evidence that any of these work at all. The only thing that these therapies decrease is the money in your pocket. The gold standard for sweating is surgery and currently it is recommended as the first choice therapy. By being informed and seeing a reputable physician, the individual can save himself a lot of money and aggravation by avoiding all the nonsensical and quack methods.