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
treatment of localized hyperhidrosis
on a scale of 1 to 4 (1 = slight, 4 = severe)

 
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.

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 blisters^8,9, warts¹⁰, frostbites in skiers and outside workers in sub zero temperatures, soft calluses between the 4^th and 5^th 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.

Localized hyperhidrosis

Hyperhidrosis is arbitrarily classified as localized, if it does not exceed an area of 100cm², or generalized if it does exceed 100 cm^{2 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.

The control of sweating

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".

Agents anticholinergiques:

La sudation eccrine est activée par des fibres sympathiques post-ganglionnaires qui se comportent plutôt comme des fibres parasympathiques ou cholinergiques.

Draw backs of anticholinergics:

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.

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  solutions^22,23. 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 effect^26,9.  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.

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