Hyperhidrosis: the sweating disease

Snapshots of hyperhidrosis

We're at a college football game on a comfortable September day sunny and warm, but not hot. As we cheer for a great pass and an acrobatic reception, I lean over to my friend and whisper, ?Um, you're sweating a lot again.? I'm trying to help her avoid the embarrassment of anyone else seeing the grapefruit-sized sweat stains on the armpits of her green t-shirt. So she sits quietly with her arms at her sides, afraid to even wave to friends who pass by.

While teaching a workshop at a client site, I notice (as did everyone else in the room) that one of my co-presenters was sweating profusely from the armpits and even on the middle of his back. I returned to the office after the trip to learn that the client was upset that he had been sweating. They felt it was ?unprofessional.?

The different types of hyperhidrosis

The social and professional problems associated with profuse sweating from the armpits (called axillary hyperhidrosis) are obvious, but it doesn't end there. People with palmar (hands) hyperhidrosis are afraid to shake hands, write on paper, or handle paper products at all. The foot sweat from plantar hyperhidrosis creates a bad odor and ruins some shoes with a permanent odor. Facial sweating is obviously embarrassing as everyone can see the perspiration on your face. Like axillary sweating, perspiration from truncal (torso) hyperhidrosis also can show through clothing.

What causes hyperhidrosis?

The answer, in many cases, is unknown. This is called primary hyperhidrosis, because the sweating is not a symptom of another underlying condition. It is also referred to as idiopathic, again because the cause is unknown.

Although, the actual cause of hyperhidrosis is unknown, the mechanism by which the excessive sweating occurs is pretty clear. The sympathetic nervous system the part of the nervous system that we do not control sends signals to the sweat glands telling them to produce and eject sweat. Excessive sweating occurs when this system sends signals to produce more sweat than is needed to maintain body temperature. The big question is why?

For some people with hyperhidrosis there are answers. These people actually have another condition that is causing the excessive sweat. Called secondary hyperhidrosis, this can be caused by the following conditions:

• hyperthyroidism and other endocrine diseases
• obesity
• menopause
• use of antidepressants
• endocrine treatment for prostate cancer or other malignant diseases
• central nervous system disorders
• severe psychiatric disorders

What about stress? Though stress seems to worsen hyperhidrosis, most physicians don't consider it a cause. ?The nervous system is geared to sweat more [in people with hyperhidrosis], so the sweat response is more sensitive to stress in these people,? explains Ib Odderson, M.D., of Overlake Medical Center in Bellevue Washington.

Is there anyway to stop the waterworks?

Yes, though in many cases the goal of treatment is to manage the disease rather than cure it entirely. Treatments for hyperhidrosis work to varying degrees depending on the type and severity of the condition.

There are no drugs specifically to treat hyperhidrosis. Some sedatives and anticholinergic drugs can reduce the sweating to some degree, but are not used because their side effects dry mouth, blurred vision are considered worse than the sweating.

Caffeine is one drug that should be avoided because it belongs to a class of chemicals that stimulate eccrine sweating. Though they do not specifically cause hyperhidrosis, caffeine and spicy foods can exacerbate the problem.

Treatments for light to moderate cases

• Antiperspirants - Used for armpit sweating, these prescription antiperspirants (i.e., Drysol) contain 20-25% aluminum chloride and 70-90% alcohol. Drysol is applied two to three times per week. Important note for women: You cannot put this on your armpits after you have shaved, because it can cause severe stinging. Drysol also may lose its effectiveness in a matter of a few months.
• Iontophoresis or electrophoresis - If the prescription antiperspirants don't work, this procedure can be helpful for periodic hyperhidrosis (as in just before a formal affair). A battery-powered electrical device is used to apply an electrical current to the affected area. This procedure needs to be repeated on a daily or weekly basis, eventually tapering off to every one to two weeks.

Treatments for severe cases

For people whose sweating is profuse, dermatologists and neurologists are using the following techniques to help them.

• Axillary liposuction> By suctioning out the fat just under the skin of the armpit, the sweat glands of the armpit can be removed. This outpatient surgical procedure takes about 90 minutes and is performed with local anesthesia.
• Endoscopic thoracic sympathectomy Using a fiberoptic surgical tube inserted through the neck or the underarm, a surgeon cuts the nerve fiber responsible for transmitting messages to the sweat glands. This procedure is used to relieve sweaty palms, face and armpits. Unfortunately, the nerve fibers responsible for plantar sweating are only accessible through a major abdominal surgery called lumbar sympathectomy.

The latest treatment

Botulinum toxin injection (Botox )

- In very small doses botulinum toxin reduces sweating by blocking the messages that nerves send to sweat glands telling them to produce too much sweat. One treatment keeps most people dry for four to ten months and has to be repeated. It is also quite expensive, estimated at $350-400 each session.

A talk with the experts

The treatments for severe hyperhidrosis are being studied to determine their efficacy. Here's what experts in the field have to say:

"As a general rule, most people should try the [Botox] injections first, because there are no permanent long-term risks," advises Dr. Glogau of the University of California, San Francisco. "With surgery there are some risks," he adds.

Dr. Glogau has found liposuction to be "quite variable in its outcome." Having treated a number of patients who got only a partial response from liposuction, he reports, "I think that the choice is largely between Botox and sympathectomy."

On the other hand, Harold Brody, M.D., clinical associate professor at Emory University School of Medicine calls liposuction "a marvelous procedure" for treating underarm sweating.

Dr. Brody explained which procedures seem to work best for each type of hyperhidrosis:

• Underarms (axillary) liposuction or Botox
• Hands (palmar) sympathectomy or Botox
• Feet (plantar) Botox
• Face (facial) Dr. Glogau has had success using Botox to treat facial and scalp sweating.

So, what should you do?

If you think that you may have hyperhidrosis, see your doctor.

You are not just someone who sweats a lot. You may sweat a lot when you're exercising, but that doesn't mean you have to suffer through embarrassing sweat all day. There are several therapies that you and your doctor can discuss. And if your doctor doesn't know about this condition, find another doctor. This is not a simple case of trying a stronger deodorant.