What is Hyperhidrosis?
Hyperhidrosis is a condition characterised by excessive sweating. Sweating is the body’s natural mechanism to regulate temperature and control fluid and salt balance. We have 2-4 million sweat glands working hard to protect the body from overheating. These are mainly located in the armpits, palms of the hand, feet, forehead and cheeks.
Most of the sweat glands are referred to as eccrine glands which secrete a clear, odourless fluid to control body temperature. Apocrine glands are typically located around the armpits and genitals and secrete a thicker fluid made of protein. When this fluid encounters bacteria on the skin, it produces body odour.
Both types of sweat glands are activated by various nerves in the body in response to a stimulus. This could be our brain alerting the body’s temperature is too high or an imbalance in hormone levels. Our emotions, such as anxiety, can stimulate the activation of our sweat glands. And of course, exercise commonly causes our bodies to sweat.
In hyperhidrosis sufferers, they have more concentrated or overactive sweat glands in particular, eccrine glands. This results in an excessive amount of sweat secreted throughout the day either from the whole body (generalised hyperhidrosis) or in certain areas (focal hyperhidrosis) such as the armpits or face.
It’s estimated, hyperhidrosis affects about 3 percent of the population.
People with hyperhidrosis may notice the following symptoms:
- Visible perspiration during day-to-day activities and with little to no exertion
- Often experience beads of sweat on the skin
- Regularly ending up with sweat stained clothing
- The sweating interfering with daily activities such as opening a door, holding a pen or perspiration dripping onto their notebook or keyboard
- Skin remaining wet
- Skin peeling or particularly white in certain areas
- Frequent infections of the skin in areas of excessive sweating
What are the complications of hyperhidrosis?
Hyperhidrosis isn’t a life-threatening condition; however, it can lead to physiological problems due to the social embarrassment of excessive sweating. Sufferers can be ashamed about their wet and stained clothing or their body odour. They can be self-conscious of their wet handshake or the beads of sweating forming on their face. This emotional stress can worsen the condition and overtime, hyperhidrosis can interfere with the sufferer’s daily life and relationships.
In addition to the physiological problems, hyperhidrosis predisposes people of skin problems. When the skin is continually wet, it can breakdown and the moist environment can lead to infections such as tinea pedis commonly known as athlete’s foot. Tinea cruris or ‘jock itch’ is another fungal infection that can occur due to the sweating. People with hyperhidrosis are also more susceptible to skin conditions such as eczema, warts and rashes.
Body odour is another common complaint of hyperhidrosis sufferers. While the sweat secreted from eccrine glands is generally odourless, it’s when it comes into contact with bacteria that it smells. Underarm and genitals are areas of the body most prone to producing odour. Those who wear tight shoes or no socks may also experience smelly feet.
What causes hyperhidrosis?
The exact causes of hyperhidrosis are not well understood. The condition tends to occur without direct provocation and can be worsened by exercise, stress or a humid/hot environment.
There are two main types of hyperhidrosis indicating the causes:
Primary focal hyperhidrosis:
Primary focal hyperhidrosis is when the condition is not caused by a medical condition or a side effect of a pharmaceutical drug. This is the most common form of hyperhidrosis.
Focal hyperhidrosis occurs in specific areas such as the armpits, palms or face. It usually presents symmetrically, meaning the sweat is experienced on both sides, and occurs during day time.
This form of hyperhidrosis usually occurs in childhood or adolescence. It is also strongly linked to familiar history with many patients having siblings or parents with the condition.
Diagnosis of primary focal hyperhidrosis can be made on the history of the condition if the patient has experienced excessive sweating for at least 6 months and had two or more of the following:
- Onset before 25yrs old
- A positive family history
- Bilateral, symmetrical sweating
- Impaired daily activities
- Sweating that stops while sleeping
Secondary generalised hyperhidrosis:
Secondary hyperhidrosis is caused by an underlying medical condition or a side effect of pharmaceutical medication. Typically, people with secondary hyperhidrosis experience excessive sweating all over their body, which is why it’s labelled ‘generalised’. This form of excessive sweating usually occurs in adulthood and is more problematic while sleeping.
There are various medical conditions that could cause secondary generalised hyperhidrosis with the most common being hyperthyroidism, lymphoma, menopause, obesity, alcoholism, diabetes mellitus, acute febrile illness, heart failure, Parkinson’s disease and Rheumatoid Arthritis.
There is also a long list of medications that list the side effects of excessive sweating such as common medications like beta blockers, statins insulin regulators or antidepressants.
Hyperhidrosis treatment and prevention
There are several lifestyle measurers people can take to help reduce the severity of hyperhidrosis including avoiding spicy foods or body products containing chemicals. Wearing loose clothing of natural materials can help, as well as changing shoes regularly.
Proper hygiene and antiperspirant products can help reduce sweating, and deodorants will act to disguise any unpleasant body odour if present.
There are several non-surgical and surgical treatments available for the treatment of primary focal hyperhidrosis. However, the management and treatment of secondary generalised hyperhidrosis requires addressing the underlying causes.
Non-surgical treatments of hyperhidrosis
Topical antiperspirants containing aluminium may help in the management of focal hyperhidrosis and are typically the first line therapy. Although these are found in the supermarket, prescription-strength antiperspirants may contain aluminium chlorohydrate or chloride hexahydrate which are much more effective at obstructing the eccrine gland duct.
For optimal results, its recommended the antiperspirant is applied to clean, dry skin at night and washed off in the morning. The concentration of aluminium chloride hexahydrate will be gradually increased to avoid the common side effects of skin irritation, tingling and burning.
In the event antiperspirants haven’t been successful at reducing the excessive sweating, iontophoresis therapy may be offered.
Iontophoresis therapy uses a medical device to deliver a low-voltage current into the skin of either the palms or soles of the feet. Tap water or the chemical glycopyrrolate is used to conduct the current with the latter being more effective. The process takes about 15-40 minutes and is often repeated three times per week, until the sweating has resolved. For long term success, patients will then proceed with a maintenance schedule of once a week. Success rates of iontophoresis therapy vary between 60-80%.
Iontophoresis therapy has a potential side effect of skin irritation. There are no serious side-effects found and the benefit of this treatment is considered long-term.
Botulinum Toxin Injections
Botulinum toxin type A injections is a newer treatment for hyperhidrosis that has demonstrated to be effective at significantly reducing excessive sweating. When injected, Botulinum toxin blocks the release of acetylcholine which is the chemical that stimulates the eccrine sweat glands.
Medicare subsidies the use of these injections in patients over the age of 12 with primary axillary hyperhidrosis (excessive underarm sweating) that has no responded to topical antiperspirants. The treatment is also effective on the palms and soles of the feet; however, this is current a non-Medicare subsidised treatment.
The effects of Botulinum toxin injections last an average of 8 months, with some patients enjoying the benefits up to 12 months. Side effects are minimal and uncommon, but can include pain, temporary weakness in the hand muscle and some compensatory sweating.
There are several oral medications that can help in the management of excessive sweating where the above non-surgical treatments have failed. These are best suited for patients with certain hyperhidrosis conditions including generalised hyperhidrosis and facial sweating. The medications are also prescribed to resolve compensatory sweating post-surgery, temporary relief for a special event or to reduce the perspiration side effects of a medication.
Anticholinergics are the most commonly used pharmaceutical drugs to manage excessive sweating which include Propantheline bromide and oxybutynin. These are found to be highly effective and an affordable solution at working systemically. This means, they can’t target one particular area of the body and decrease sweating over the entire body. This does put patients at risk of overheating if they are not careful. Other side effects of anticholinergics include dry mouth and eyes, headaches and urinary retention.
Beta Blockers and Benzodiazepines are other medications that can help treat patients with hyperhidrosis that is stress induced. These drugs act on the central nervous system by blocking the physical symptoms of anxiety. The side effects of dependency stipulate that the drugs should only be used short-term.
In severe cases of hyperhidrosis where topical treatments have been unsuccessful and the sweating significantly impacts the patient’s daily activities, surgery is sometimes considered.
Removal of the sweat glands from under the armpits through the use of local excision can reduce sweating. However, this form of surgery can result in impairment due to scarring. Liposuction and laser glandular destruction may be a preferred and safe treatment method.
There is a risk the patient’s hyperhidrosis may return and cost for this treatment may exclude some patients.
Endoscopic thoracic sympathectomy (ETS) is a surgical procedure that is considered one of the last resorts for patients with severe hyperhidrosis. Those suffering from excessive sweating of the palms, underarms or face can be treated by ETS.
This is a serious procedure requiring general anaesthetic and involves destroying a portion of the spinal sympathetic nerve. By doing so, it disrupts the supply of the arm and hand sweat glands. Updated surgical techniques have established a less invasive method of performing this procedure and now only need to make two small incisions in the armpit to divide the nerve. This has improved recovery and reduced the scarring.
While there are some reports that ETS surgery can be reversed, the evidence is lacking that reversing the surgery is possible or results in benefits for the patient. This surgery should be considered a non-reversible operation.
Hyperhidrosis surgery side effects
As with any surgery, treatment of hyperhidrosis surgically comes with some risks which vary from patient to patient. For many where surgery is the last resort, the benefits far out way these risks but for others, surgery only presents more problems.
A common side effects of ETS compensatory sweating. This is where the excessive sweating moves from one area of the body such as the hands, face or armpits to another like the chest, buttocks or genital area. A large majority of patients who undergo ETS surgery will experience compensatory sweating to some extent. A study of 121 patients undergoing ETS at the Medical City Hospital of Dallas in Texas found 80% experienced compensatory sweating because of the surgery. An Aarhus University Hospital study in Denmark found 90% of patients reported compensatory sweating following ETS for excessive underarm sweating. For some, this to be an acceptable compromise, but for others compensatory sweating can be just as severe as their hyperhidrosis.
Other potential risks involved in ETS surgery include bleeding, inflection, lung injury and incisional pain. It is estimated the likelihood of these complications occurring is less than 1 percent.
Horner’s Syndrome is another significant complication that can occur in 1 percent of patients. This is characterised by problems affecting one side of the face only such as dropping eyelid and decreased pupil size. In some patients with Horner’s Syndrome, the problem corrects on its own over time.
A patient’s health at the time of the surgery can increase their risk of side effects. A patient with underlying emphysema or a smoker for example, is possibly at greater risk of experience lung issues post-surgery.
Hyperhidrosis surgery costs
ETS is currently listed on the Commonwealth Benefits Schedule which means a rebate is applied through Medicare or the private health insurer. As with any surgical operation, there may be additional costs to consider. Total out-of-pocket expenses for ETS surgery can range between $1,100 to $5,000.
Treatment for severe primary axillary hyperhidrosis using Botulinum toxin type A injections is also covered by the Pharmaceutical Benefit Scheme (PBS). Patients are entitled to a maximum of 3 treatments per year in a 12-month period. The benefit is also tightly regulated, with the following guidelines:
- Only available for axillary hyperhidrosis (excessive underarm sweating)
- Patients must be over the age of 12 years and must have failed or become intolerant to topical aluminium chloride hexahydrate after one or two months of treatment.
- To obtain the PBS, access to the medication can only be through Paediatricians, Dermatologists and Neurologists.
Hyperhidrosis natural treatments
To date, there is little research into the effectiveness of natural and alternative therapies in the treatment of hyperhidrosis. However, for people who want to avoid surgery, exploring these options to resolve their sweating may be worthwhile.
Most of the alternative therapies begin with adjusting the diet to include whole, unprocessed food of mostly organic produce. A gluten-free diet has been suggested to help decrease sweating. Avoidance of refined sugar, hot beverages and spicy may also help manage hyperhidrosis. Adequate intake of water is also advised.
Reducing toxins in the diet and lifestyle is also recommended for hyperhidrosis sufferers. This may include using organic body products and home cleaning products, avoid smoking, treating the home for mould and limiting the intake of caffeine and alcohol. Identifying and avoiding triggers can also improve the symptoms.
Beyond diet, natural treatments for hyperhidrosis include supplementation of both nutrients and herbs. These can include B group vitamins, Vitamin D, apple cider vinegar, witch hazel, sage, chamomile and St. John’s Wort.
Therapies and lifestyle interventions that act to relax the patient and restore system functionality are recommended. Acupuncture, hypnosis and cognitive therapy may offer potential benefits. In addition, meditation, avoidance of excessive exercises and keeping your body temperature cool may help in the management of the condition.