Treating hyperhidrosis

National report - Dermatologists should try various approaches to treat hyperhidrosis and consider the site of perspiration when choosing the appropriate therapy, says an assistant professor in the department of dermatology at the Baylor College of Medicine in Houston.

Ramsey F. Markus, M.D., discusses the advantages and disadvantages of various treatments for hyperhidrosis.

"The only treatment that has long term effects that is a concern is sympathectomy," Dr. Markus tells Dermatology Times. "What can happen is that the patient then experiences excessive sweating somewhere else in the body. It can be a permanent side effect."

Dermatologists should initiate treatment for hyperhidrosis with topical products such as aluminum chloride liquid or gel, either over-the-counter or prescription formulations, because they are mild and are non-invasive. One of the drawbacks is that they can be irritating and ineffective, Dr. Markus notes.

"If it does work, it's one of the better options from an economic standpoint," Dr. Markus says.

Anticholinergic pills, such as glycopyrrolate, help reduce overall sweating, Dr. Markus says. The common side effects are constipation and dry mouth. Rare side effects can be serious and can include cardiac arrest and arrhythmias.

"I'm always careful to give anticholinergic pills to a patient who is young and healthy, and doesn't really have any other medical problems except sweating," Dr. Markus says. "Most of the treatments are specific to the site of sweating, so they are localized. These pills are not site specific. They inhibit acetylcholine and cause an overall effect on the body. It's preferable to start with a lower dose."

Because patients need to take 1 or 2 milligram tablets two to three times daily, compliance with anticholinergic medication may be a challenge, Dr. Markus further notes.

"The patients are young and healthy and may not be in the habit of taking medication daily," he says. "In that sense, compliance with the regimen may be a problem."

Injections of botulinum toxin A, known by the trademark name Botox (Allergan), are very effective in treating axillary or underarm hyperhidrosis, Dr. Markus, who trains medical residents on the use of Botox, explains.

"It's one of the best and safest ways," he says, noting the treatment requires repeat visits annually or twice a year.

"It's easy and safe to use for the clinician. The injections last about six to 12 months. Because it's short term treatment, there will be no long term effects."

Botox can also be injected to smooth out wrinkles, but Dr. Markus believes that Botox is safe even if injected for wrinkles and axillary hyperhidrosis at the same time. For the typical injection for axillary hyperhidrosis he uses 50 units per side.

Dr. Markus says that he prefers iontophoresis over Botox when treating the hands and feet because of the pain of Botox injection in the hands. When Botox is injected into the hands or feet, wrist blocks or local anesthesia is imperative.

Iontophoresis is the most efficacious for excessive sweating on the hands and feet, according to Dr. Markus. Because the technique involves administration of an electrical current through tap water to shut off the sweat glands, it is not advisable to use it in patients who have electrical devices like pacemakers implanted in their bodies.

"It's not recommended in pregnant women nor in patients who have epilepsy, a pacemaker, or other implanted electrical devices," Dr. Markus says. "Otherwise, it's very safe."

Patients typically receive three treatments per week until sweating is under control, with the average number of treatments being 10. Maintenance treatments may be performed as infrequently as every two to four weeks.

Liposuction or curettage, like sympathectomy, is also a surgical procedure to halt excessive sweating. It is typically used for underarm sweating.