Hyperhidrosis and treatments
Hyperhidrosis is the result of excessive secretion of sweat from eccrine sweat glands. According to the International Hyperhidrosis Society (IHHS), this phenomenon occurs in more than 3% of the world’s population — roughly 220 million people. These people suffer from hyperhidrosis — a condition characterized by excessive sweating that isn’t caused by heat, exercise, or emotions. Rather, patients with primary focal hyperhidrosis often find their armpits, palms, soles of the feet, and/or face and head drenched in sweat even when they are at a comfortable temperature or resting.
Hyperhidrosis not only leads to discomfort; it also has significant effects on the quality-of-life. When someone takes a look at the DLQI (Dermatology Life Quality Index), there are scores of people with a variety of serious dermatologic diseases such as psoriasis and atopic dermatitis, well, hyperhidrosis is right up there with them in terms of the negative effects on a person’s quality of life.
For many patients, hyperhidrosis is an embarrassing condition. They don’t discuss it with their family, friends, or even physicians. Fortunately, medical specialists and researchers are taking more notice of this distressing condition and are working to perfect current treatments and develop new ones. The world of Dermatology takes a look at some of the tried-and-tested treatments and new options for patients suffering from hyperhidrosis, including:
- miraDry – microwave energy
- topical btx
- conventional treatments
- systemic treatments
1. MiraDry to treat axillary hyperhidrosis – microwave thermolysis
While several options only offer temporary hyperhidrosis treatments, the use of electromagnetic energy offers lasting relief. Microwave thermolysis provided by the miraDry device is a permanent treatment for underarm sweating. miraDry is the only non-invasive, FDA cleared, treatment to permanently eliminate the axillary hyperhidrosis. Unlike the ultrasound therapy, microwave thermolysis sends electromagnetic energy to the sweat glands two to five millimeters below the skin surface where they are heated and destroyed. miraDry uses a non-invasive handheld device to deliver precisely controlled electromagnetic energy beneath the underarm skin. Microwaves lie in the electromagnetic spectrum between infrared waves (such as LASER) and radio waves (RF devices).
The miraDry procedure is performed exclusively in Greece in the IQ Dermatology Clinics. The treatment is completed in one single session that takes about one hour. The procedure is painless, easy and the results are immediate and long-lasting. With minimal to no downtime, miraDry is indicated for primary axillary hyperhidrosis and bromhidrosis treatment in adults 18 and older as well as, in patients under the age of 18 with the consent of a legal guardian.
Btx has been a tried-and-tested treatment for this medical condition for more than a decade. It was approved for axillary sweating but it’s commonly used for other areas of the body, such as the face and the hands.
However, btx does not offer permanent relief. It lasts four months and does not cure axillary odour as miraDry does. Additionally, btx is considered off-label for treating patients under the age of 18.
3. Topical btx
For patients who are a bit squeamish about getting repeated injections, researchers are testing topical btx for hyperhidrosis. The method of treatment for the topical gel is identical to the injections in that, at the nerve endings, the toxin blocks the release of acetylcholine, the chemical messenger which directly stimulates the sweat glands. Instead of being injected, a proprietary peptide attached to the toxin actively transports it through the skin.
The gel was tested on a number of patients with axillary hyperhidrosis, however, the studies have not yet been completed confirming the appropriate dose and duration of the treatment. In addition, topical btx can’t be used to treat palmar and plantar hyperhidrosis and the injectable btx by hand is pretty cumbersome and painful.
While btx is proving to be effective in blocking the mechanism that causes sweat, other therapies – (see miraDry) – seek to completely destroy the sweat glands. Destroying the glands was probably the first thing that was ever done to treat this condition. Surgically, physicians just cut out that area, put in skin grafts and the glands were removed. It’s not a very pleasant treatment to go through. However, the destruction method has evolved over the years with the introduction of the use of ultrasound. By using the images produced by the ultrasound, dermatologists can locate the sweat gland and focus a beam of ultrasound energy on the gland to heat and destroy it.
In contrast to the miraDry system, this method has not yet been approved by the FDA. But micro-focused ultrasound is approved in general, so people can use it. It certainly works, however, more research will be needed to determine the most effective energy levels for different depths of the skin when using this treatment.
Also, it is painful and is not a good treatment option for palms and soles as it’s much more difficult to treat those glands because they are deeper in the skin.
LASER therapy is a relatively new treatment for hyperhidrosis. It uses the LASER energy to destroy a satisfactory number of the sweat glands to reduce the sweating to normal. Although still a concept in its infancy, using LASER for hyperhidrosis is showing potential and it also has few side effects. A single treatment using a 1440-nm Nd:YAG LASER has the capability to directly target the sweat glands without affecting other aspects of the skin or damaging blood vessels or nerves. However, the therapy is currently only applicable to axillary hyperhidrosis and is not a solution for excessive sweat in the hands and feet because of the thickness of the skin.
6. Conventional treatments
Before miraDry, btx injections, ultrasounds, and LASER, there were more conventional modalities available for hyperhidrosis patients — many of which are still viable options today. Aluminum chloride has been used in antiperspirants since the early 1900s to curtail excessive sweating, with minimal side effects — itching and stinging — reported. Aluminum chloride preparations and the newer clinical strength antiperspirants which rely on more complex aluminium zirconium salts — do have some degree of effectiveness, but they are not working as regards extra excessive sweating. Similarly, these antiperspirants have little effect on palmar and plantar cases.
Another conventional treatment for hyperhidrosis is iontophoresis — a therapy that has been used since the 1940s. Patients put their hands and feet in a water iontophoresis machine for 20 to 40 minutes about three or four times a week. The device shoots mild electrical currents through the water; the water passes through the skin’s surface which causes sweating to stop. The theory behind this treatment option, however, is a bit fuzzy.
Iontophoresis is particularly helpful in treating patients with plantar and palmar hyperhidrosis. Conversely, this treatment is not ideal for axillary, face, and groin cases given the way treatment is delivered.
7. Systemic treatments
While many of the treatments for hyperhidrosis are specific to one or two areas of sweating, systemic treatments offer patients who sweat in multiple areas some relief. We used to believe that hyperhidrosis was just in the underarms or hands, but what we have discovered is that patients may have a little under the breast, in the groin or maybe in the back of the neck. For patients who sweat excessively as a result of anxiety and stress, beta-blockers (propranolol) that slow down the heart rate and lower blood pressure may offer some relief. Similarly, alpha adrenergic agonists (clonidine) can work for patients with menopausal-related sweating, or those who sweat as a result of anti-anxiety or anti-depressant medications. For the general hyperhidrosis patient, where anxiety, menopause, and/or medications are not the primary drivers behind the sweating, oral drugs (glycopyrrolate, oxybutynin, benztropine, and propantheline) may provide some relief. While off-label and not FDA-approved for hyperhidrosis, these drugs are effective for patients with multiple affected sites because they block the release of acetylcholine from the nerve ending.
However, they have multiple side effects such as dry eyes, dry mouth, constipation and significantly decreased sweating. Overall, oral drugs can be a viable option for hyperhidrosis patients as a monotherapy. They must be used in combination with other focal treatments, such as a topical prescription antiperspirant or btx for the underarms.