|
|
Excessive Sweating (Hyperhidrosis) By
Antranik Benohanian MD, FRCPC Dermatologist
at the Montreal University Hospital Center ( Hôpital Saint-Luc) Excessive
sweating, is a somewhat neglected topic in the medical literature. Physicians
either ignore it or do very little to alleviate it. People suffering from
this disorder, usually young adults and adolescents, feel frustrated because
the advice from their physicians varies from no treatment at all to expensive
procedures such as iontophoresis, botox injections or sympathectomies. The
general public remains confused and does not know what to do and where to
go. I
decided to create this web site after treating over 5 thousand patients in
the last 23 years. The goal is to
inform the public that there are simple solutions that most of the time solve
lifelong problems of hyperhidrosis. The therapeutic options vary according to
the age of the patient, the area involved, the severity of the disease and
the patient’s tolerance. Ideally, the optimal therapeutic choice at the least
cost should be sought in collaboration with the dermatologist or the treating
physician. Extemporaneous formulations, tailored to the patient’s need, could
be compounded by knowledgeable pharmacists. Therapeutic ladder proposed for the
Definition: The purpose of sweating is to keep
a constant body temperature around 37°C through evaporative cooling. We speak of
hyperhidrosis when the amount of sweat largely exceeds the quantity required
for thermoregulation. [Hyperhidrosis = hyper + hidrôs (sweat)] Prevalence: The popular belief is that
sweating is a physiological phenomenon that should be respected even when it
causes physical and psychological embarrassment. It follows that the number
of people seeking for assistance is far less than expected. Many people
suffering from hyperhidrosis are embarrassed to reveal their problem,
considered as a taboo in our present-day society. There is no predilection
among men and women even though women seek more often advice for this
problem. The incidence of hyperhidrosis is
higher among children, teenagers and young adults. It
is estimated that roughly 1% of the population suffers from
hyperhidrosis1.
Less than 10% of these suffer from generalized hyperhidrosis while the great
majority suffers from localized hyperhidrosis which mainly involves the
axillae the feet and the hands, in that order of frequency. Rarely, the
forehead and the groins are also involved. 25 % of individuals affected with
palmar or plantar hyperhidrosis have also axillary hyperhidrosis2. Family
history is positive in 90% of the cases. Nine out of ten North Americans use an antiperspirant or deodorant on
a daily basis. Although the vast majority of the population is well served by
these products, there has been no serious effort displayed by the cosmetic
and pharmaceutical industry to care about the 1% of the population who suffers
from excessive sweating. Their small number will probably never justify big investments. In
fact, a quick look at the last edition of the Canadian “Compendium of
pharmaceuticals and specialties” will let you realize that there is only one
product under the heading “Anhidrotics”. Available information is relatively
scarce in the medical literature3 . This may explain why
the great majority of physicians are helpless in dealing with hyperhidrosis
and why people victim to hyperhidrosis continue to suffer in silence from
that disorder. The Impact of hyperhidrosis on the quality of life Hyperhidrosis may be embarrassing and sometimes disabling. It can ruin
one’s social and professional life. On the feet, excessive
sweating represents a favorite medium to trigger a host of
dermatological diseases such as :
pitted keratolysis, bromhidrosis4,
tinea pedis5,
eczema, dyshidrotic eczema (pompholyx)6,
contact dermatitis7, friction blisters8,9,
warts10,
frostbites in skiers and outside workers in sub zero temperatures, soft
calluses between the 4th and 5th toes11
and even ingrown nails12.
On the other hand, shoes will be burnt and destroyed by the sweat at an accelerated rate13. There has been a case report where
combined Gram negative and fungal infections on the feet have resisted
intravenous antibiotics in the presence of hyperhidrosis14. On the hands, hyperhidrosis can stain books and
papers, makes the fingers slippery on computer keyboards and even prevent us
from playing our favorite sports like baseball golf or tennis. Slippery hands
can easily drop objects and manual work becomes difficult and prone to injury
because of the difficulty in holding instruments safely. People with sweaty palms will not qualify for
certain jobs like a hairdresser or a health professional. A
moist and cold handshake will not inspire confidence in a job interview.
Other jobs like working in a cafeteria or a bakery will be difficult.
Excessive sweating may even disable mucisians15.
Politicians and speakers who sweat will have a hard time to convey their
message to their audience because sweat conveys anxiety and lack of
confidence if not incompetence. On the armpits, excessive sweating will stain and
ruin expensive clothing besides causing tremendous embarrassment. Hyperhidrosis is arbitrarily classified as localized, if it does not
exceed an area of 100cm2, or generalized if it does exceed 100 cm2 16. Localized hyperhidrosis is also known as primary, idiopathic or
essential hyperhidrosis. Sweating is often triggered by anxiety and fear.
Certain substances will also trigger hyperhidrosis like coffee, tea, cola
drinks, chocolate and spices. In this type of hyperhidrosis, the armpits, the
hands and feet are most often involved, but the forehead, the groins and the
perineum could also be affected. Primary hyperhidrosis is almost always symmetrical. An asymmetrical
hyperhidrosis should always be suspicious of an underlying pathology. The
sweat glands are most active during the day. Generalized hyperhidrosis Generalized hyperhidrosis occurs following fever, exercise, an
increase in air temperature and other triggers such as, anxiety, spicy foods
and many drugs. Sweating, like fever and shivering, is one of the main signs and
symptoms that allow us to reach an accurate diagnosis during the assessment
of many diseases. Many medical specialties like : internal medicine,
endocrinology, neurology, neurosurgery, dermatology, psychiatry to name only
a few, are often implicated in its evaluation. Night sweats are more commonly associated with
infection, classically tuberculosis, brucellosis or even
a lymphoma. The diagnosis of hyperhidrosis poses no problem as the sweat droplets
on the affected area or the staining of the clothing covering that same area
are more than enough to confirm it. Sweat is secreted by the eccrine glands, present all over the body,
that play an important role in thermoregulation. People devoid of sweat glands
have a hard time in maintaining a stable body temperature. However, some
areas, like the palms and soles do not really contribute to this thermoregulation17.
Sweating in these areas are triggered more by emotions then heat. Moreover,
in individuals who are somewhat emotional, "flushing" adds up,
making an already embarrassing situation even worse. There are about 3 millions sweat glands, of the eccrine type, covering
our skin surface from head to toe. Their density varies from one part to
another. The back contains 64 glands
/cm2, the forearm 108 glands/ cm2, and the forehead 181
glands/ cm2. The palms and soles contain each from 600 to 700
glands / cm2. The thermostat that regulates the body temperature is located in the
hypothalamus. When the body temperature goes over a certain level, the
sweating phenomenon is activated through the sympathetic nervous system, the
cutaneous nerves and the nerve terminals responsible for the sweat secretion.
In the case of primary hyperhidrosis, nervous impulses triggered by emotions
reach the hypothalamus which begins the sweat process. Medications and toxic agents
triggering hyperhidrosis: Among the most important triggers are: pilocarpine, physostigmine,
acetaminophen, aspirin, insulin, niacin, antidepressants, meperidine,
tamoxifen. Alcohol and alcohol withdrawal syndrome, opiates and cocaine may also trigger sweating. Systemic Treatment: Psychotherapy: Sometimes a minor sedative that controls the stress, is enough to stop
the sweating. But, this measure will induce only a partial remission. Some
individuals may respond better to medications like amitriptyline and
hydroxyzine which have sedative or anticholinergic effect, while others
respond to "Biofeedback". Anticholinergics: Eccrine sweating is activated by post-ganglionic sympathetic fibers
which act as cholinergic fibers.
Draw backs of anticholinergics: Unfortunately, the anti-cholinergic effects generated by these
medications are worse than the sweating itself : tachycardia, dry mouth,
sluggishness of the intestinal motility, worsening of certain conditions like
: glaucoma, toxic erythema, convulsions etc.. Moreover, these symptoms appear
long before the sweat is under control. It follows that anticholinergics have
little place in the management of hyperhidrosis. There are
reports in the literature where cases have responded
to the following medications
Antiperspirants and deodorants The aim of an antiperspirant is to decrease the amount of sweating by
creating a plug in the acrosyringium. The plug is made of aluminum salts. Deodorants, on the other hand are products aimed at decreasing the
odor with an antibacterial agent or masking it with a perfume. Treatment of localized hyperhidrosis Aluminum chlorhydrate Present in most antiperspirants available over the counter. Its
concentration is higher in antiperspirants than in deodorants. Among the
aluminum salts, aluminum chloride is the most effective followed by aluminum chlorhydrate
/ zinc compounds and finally aluminum chlorhydrate used alone. Aluminum
chloride hexahydrate in an
alcoholic solution Aluminum chloride hexahydrate is available as a 20% alcoholic solution
Drysol® and at 6% concentration under the name Xerac ac®. Aluminum chloride hexahydrate has to be used in special way. The
armpits, hands and feet must be thoroughly washed and blow dried before its
application. The solution is applied under occlusion with Cellophane paper in
resistant cases. Gloves and plastic bags may be used for the hands and feet.
Occlusion is kept overnight. This procedure is repeated 2 to 3 nights per week.
Irritation is a common side effect. Stinging and burning sensation are common
at the beginning but may subside after a while20. Aluminum
Chloride Hexahydrate in a salicylic acid gel base In 1978, Aluminum Chloride Hexahydrate in a salicylic acid gel base
was tried for the first time in a middle aged woman who was on the verge of
getting a surgery for her axillary hyperhidrosis after failing to respond to
Drysol under occlusion. The patient asked me for a stronger formulation than Drysol in order
to avoid surgery if possible. I prescribed her 20% aluminum chloride in a
salicylic acid gel base which was available on the market then for the
treatment of acne. The preparation was to be applied at night after thoroughly
drying the armpits, without occlusion. Because I was anticipating a strong
reaction to develop from the presence of two potentially irritant substances i.e.:
20% aluminum chloride and 4% salicylic acid , I instructed my patient to wash
the armpits as soon as a reaction develops and to apply a 1% hydrocortisone
cream. To my greatest surprise, an ecstatic patient called me the following
day to notify me that not only the formulation worked, but was also better
tolerated than the alcohol solution previously used. When her surgeon became
aware of the success of this treatment, over a 100 similar cases were referred to me during that same year.
A
few references on the treatment of hyperhidrosis with aluminum chloride in a
salicylic acid gel base
Why did I chose an alcoholic gel instead of the alcoholic solution? Even though absolute ethanol (
95%) has been the traditional vehicle in which aluminum chloride hexahydrate
has been dissolved for a great number of years, the fact remains that alcohol
may cause an unbearable irritation in some patients. There
are few reports that testify that alcohol gels are less irritating and better
tolerated than alcohol solutions22,23. Moreover,
aluminum chloride in its alcoholic base does not penetrate adequately through
the thick horny layers present on the palms and soles to exert its
antiperspirant effect effect24.
The role of salicylic acid in this formulation is to enhance the penetration
of aluminum chloride through the thick horny layers and, having antiperspirant
properties of its own25,
it could act synergistically with aluminum chloride to enhance the required
antiperspirant effect26,9.
Occlusion with Cellophane paper becomes unnecessary with this formulation. Aluminum salts create a plug at the end of the
sweat duct (acrosyringeum) near the skin surface which will induce structural
changes in the axillary eccrine glands on the long run27, thus diminishing the sweat flow which in its
turn will diminish the need for antiperspirants. Treatment with this
formulation could be as rare as once a month. The following factors should be
taken into account when prescribing aluminum chloride formulations: the age
of the patient, the affected site, the severity of hyperhidrosis and the
patient’s tolerance. The
concentration of aluminum chloride should be adjusted accordingly. Treatment with Botox
injections Botox injections are used to stop sweating on the armpits28 , hands29 and feet.
The mechanism of action of Botox is through its effect on acetyl choline
present on the nerve synapses. Topical glycopyrollate as 0,5% aqueous solution has been reported also
to control hyperhidrosis of the forehead30. There is no doubt that extemporaneous formulations may pose a problem
of stability and reliability and may require a lot of time and effort from
the part of the pharmacist to bring about the right formulation. But, a happy
and grateful patient makes all that effort worthwhile. References 1.
Adar R. Zurchin A,
Zweig A,Mozes M. Palmar hyperhidrosis and its surgical treatment: a report of
100 cases. Ann Surg. 1977.186:34-41 2.
Sato K. Biology of
sweat glands and their disorders II. Disorders of sweat gland function J Am
Acad Dermatol 1989.20:713-726 3.
Leung AK; Chan PY;
Choi MC. Hyperhidrosis. Int J Dermatol. 1999;38:561-7 4. Takama H; Tamada Y; Yano K; Nitta Y;
Ikeya T. Pitted keratolysis: clinical manifestations in 53 cases. Br J
Dermatol 1997;137:282-5 5.
Stratigos AJ; Stern
R; Gonzalez E; Johnson RA; O'Connell J; Dover JS. Prevalence of skin disease
in a cohort of shelter-based homeless men. J Am Acad Dermatol 1999;41:197-202 6.
Yokozeki H; Katayama
I; Nishioka K; Kinoshita M; Nishiyama S. The role of metal allergy and local
hyperhidrosis in the pathogenesis of pompholyx. J Dermatol 1992;19:964-7 7.
Berndt U; Hinnen U;
Iliev D; Elsner P. Is occupational irritant contact dermatitis predictable by
cutaneous bioengineering methods? Results of the Swiss Metalworkers' Eczema
Study (PROMETES). Dermatology 1999;198:351-4 8. Knapik JJ; Reynolds K; Barson J.
Influence of an antiperspirant on foot blister incidence during cross-country
hiking. J Am Acad Dermatol. 1998;39:202-6 9. Benohanian A; Dansereau A. Influence of
an antiperspirant on foot blister incidence during cross-country hiking. J Am
Acad Dermatol. 1999;41:655-6 10. Mergler D; Vezina N; Beauvais A. Warts
among workers in poultry slaughterhouses. Scand J Work Environ Health 1982;8
Suppl 1:180-4 11. Singh D, Bentley G, Trevino SG. Fortnightly Review:
Callosities, corns, and calluses. BMJ 1996;312:1403-1406 12. Steigleder GK; Stober-Munster I.
[Syndrome of the ingrown nails?] Z Hautkr 1977;52:1225-9 13. Freeman S. Shoe dermatitis. Contact
Dermatitis 1997 May;36(5):247-51 14. Shelley WB; Shelley ED. Recalcitrant
unilateral infection associated with congenital leg hypertrophy cleared by
control of hyperhidrosis. Cutis 1984 Mar;33(3):281-2 15. Onder M; Aksakal AB; Oztas MO; Gurer MA. Skin problems of
musicians. Int J Dermatol 1999;38:192-5 16. Sato K; Ohtsuyama M; Samman G. Eccrine sweat
gland disorders. J Am Acad Dermatol 1991;24:1010-4 17. Kerassidis S. Is palmar and plantar
sweating thermoregulatory? Acta Physiol Scand 1994;152:259-63 18. Goldyne ME: Indomethacin and
Hyperhidrosis. (Letter) J Am Acad Dermatol1982. 6: 545 19. James WD, Schoomaker EB, Rodman OG. Emotional
eccrine sweating. Arch Dermatol 1987.123:925-9 20. Shelley WB; Hurley HJ Jr. Studies on topical
antiperspirant control of axillary hyperhidrosis. Acta Derm Venereol
1975;55(4):241-60 21. Benohanian, A: La bromidrose. Le
Clinicien1996;11(10):131-152 22. Comes DA, Dolan MJ,
Fendler EJ, Turner TK, Williams RA.Effects of alcohol on human skin: AAD
poster 1997 23. Newman JL, Seitz
JC.Intermittent use of an antimicrobial hand gel for reducing soap-induced
irritation of health care personnel: Am J Infect Control, 1990 Juin,
18:3,194-200 24. White JW. Treatment
of primary hyperhidrosis. Mayo Clin Proc1986. 61:951-6 25. Martindale, the Pharmaceutical Press. The extra Pharmacopoeia, 27th
edition 212-213 26. Benohanian A;
Dansereau A; Bolduc C; Bloom E. Localized hyperhidrosis treated with aluminum
chloride in a salicylic acid gel base. Int J Dermatol. 1998.;37:701-3Int J
Dermatol. 1998;37:701-3 27. Hölzle E, Braun-Falco
O: Structural changes in axillary eccrine glands following long-term
treatment with aluminium chloride hexahydrate solution. Br J Dermatol
1984.110:339-403 28. Bushara KO, Park DM, Jones JC, Schutta
HS. Botulinum toxin, a possible new treatment for axillary hyperhidrosis.
Clin Exp Dermatol, 1996 July, 21:4, 276-8 29. Schnider P, Binder M, Auff E, Kittler
H, Burger T, Wolff K. Double-blind trial of botulinum A toxin for the
treatmen 30. Seukeran DC; Highet AS. The use of
topical glycopyrrolate in the treatment of hyperhidrosis. Clin Exp Dermatol 1998
Sep;23(5):204-5
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
