APRIL 15, 2006


No sweat: helping your
hyperhidrosis patients

As a teenager Corrine G was frequently teased by her classmates for her excessive, uncontrollable sweating. She mentioned it to her doctor, who chalked it up to hormones. Her symptoms did get a little better as she got older, but she still always wears black to hide the stains and avoids physical contact whenever possible. Patients like Corrine who suffer from hyperhidrosis (HH) — up to 2.8% of the population, according to recent surveys — sweat more than the body actually needs to maintain optimal body temperature. Left untreated, the condition can have debilitating effects on patients' social, personal and professional lives. "It's an embarrassing thing because it conveys the message that they're not confident," says Dr Antranik Benohanian, a dermatologist at St Luc Hospital in Montreal. "They need to know that something can be done."

There are two types of HH. Focal, or primary HH, is localized to the armpits, feet, hands or face, in that order of frequency. The cause is poorly understood, but Dr Benohanian says there are indications that genetics may be involved. Generalized HH, on the other hand, occurs over the whole body and is actually caused by an underlying condition. "In that case you need to ask patients if they have any other discomforts or symptoms," suggests Dr Youwen Zhou, a dermatologist at the Hyperhidrosis Clinic at Vancouver General Hospital.

Ten take-home tips

To reduce sweat and body odour, tell your patients to:

  1. Wear light-coloured, loose fitting clothing
  2. Avoid polyester, silk and artificial fibers
  3. Wear natural cotton perspiration shields under clothing
  4. Use antiperspirant with aluminum chloride
  5. Take a bath or shower daily
  6. Alternate shoes daily
  7. Go barefoot when possible
  8. Eliminate foods or drinks that exacerbate sweating (like spicy foods and hot beverages), as well as foods with strong odours like onions and garlic
  9. Drink lots of water
  10. Visit a dermatologist or sweat specialist. To find one in your area, go to www.sweatmanagement.ca

Dr Benohanian adds generalized sweating is usually idiopathic, but can also be a sign of thyroid disease or diabetes. "Night sweats usually point to Hodgkin's disease, infections or tuberculosis," he says.

Both experts agree the diagnosis of focal HH is pretty straightforward. "It's a functional definition, meaning that the amount of sweat may vary," explains Dr Zhou. "It's the amount of discomfort and inconvenience that's used as the criteria." He suggests asking patients how much their sweating bothers them: never, sometimes, usually or always, to determine the severity of the condition.

Unfortunately, there are very few things that patients can do on their own to control excessive sweating, but certain triggers can exacerbate it. "Any strong emotion or stressful situation can make it worse," says Dr Benohanian. "Hot beverages, spicy foods should also be avoided."

There are lots of ways to minimize excessive sweating, ranging from topical treatments to surgery. A well-informed GP should be able to discuss these options with patients and deliver the crucial message that solutions are available. "The worst thing to tell patients is that nothing can be done and they should just 'tough it out'," says Dr Benohanian.

Topicals Treatment varies according to the location and severity of the condition. GPs should always start with topical therapies. Prescription antiperspirants and topicals containing aluminum chloride (AlCl) are the most effective, but they can be quite irritating to the skin. Dr Benohanian says a 1% hydrocortisone cream is usually helpful in these cases. Over-the-counter antiperspirants, on the other hand, contain the less potent aluminum chlorhydrate, which is less of an irritant. For HH affecting the hands or feet, AlCl solutions are usually ineffective because the thick, horny layer of skin impedes absorption. In these cases, AlCl can be mixed in a salicylic acid gel base.

Botox Studies have shown that injection of Botulinum toxin type A is 83-95% effective in reducing sweating. Most private drug plans cover Botox, as do the provinces of Quebec, Manitoba, Alberta, Saskatchewan and Nova Scotia. "Botox injections can be cost-effective," says Dr Zhou, "Patients usually don't need to come in more than once or twice a year." While Botox injections are relatively painless in the armpits and face, the densely innervated skin of the hands and feet make it much more painful. "Having a nerve block [basically the injection of a local anesthetic near a peripheral nerve] on the wrist or ankle is a practical way of freezing the nerves," says Dr Benohanian. Alternatively, a needle-free device can be used to deliver minute amounts of lidocaine prior to the injections.

Iontophoresis Though less effective than Botox, iontophoresis can still benefit a significant number of patients with localized HH in the hands and feet. The affected area is immersed in a tray that contains tap water, and a mild electrical current is passed through the liquid, disrupting the function of sweat glands. The cost of a home machine ranges from $200-$1,200. Unfortunately, the inexpensive units tend to be much less effective. "The treatment must be done several times a week initially, then patients can gradually decrease to a maintenance regimen," explains Dr Zhou.

Surgery Dr Zhou says that because of recurrence, complications and rebound HH, surgery is left as a last resort. Endoscopic thoracic sympathectomy, or ETS, is an invasive procedure where the nerves causing abnormal sweating are clipped. The other option is surgical excision of the axillary glands. "I have seen over 5,000 patients, and I've only sent three for ETS," says Dr Benohanian. "It should be avoided whenever possible."



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