HYPERHIDROSIS
(excessive sweating)

italianodeutschрусский

© 1995 Ivo Tarfusser, MD
Upd.: 1999

Iontophoresis therapy for hyperhidrosis



Overview

Sweating is a natural phaenomenon necessary for the regulation of an individual's body-temperature. The secretion of sweat is mediated by a portion of our vegetative nervous system (the Sympathetic Nervous System). In some people (approximately 1% of the population), this system is working at a very high activity level, far higher than needed to keep a constant temperature. This condition is referred to as hyperhidrosis.

Classification and Causes

1. Hyperhidrosis as part of an underlying condition (secondary hyperhidrosis)
Some conditions can promote excessive sweating, as a rule involving the whole body:
* Hyperthyroidism or similar endocrine diseases
* Endocrine treatment for prostatic cancer or other types of malignant disease
* Severe psychiatric disorders
* Obesity
* Menopause
2. Hyperhidrosis without known cause (=primary or essential hyperhidrosis)
This is a far more frequent condition than secondary hyperhidrosis and appears, generally, localized in one or several locations of the body (most often hands, feet, armpits or a combination of them). It usually starts during childhood or adolescence and persists all life. Nervousness and anxiety can elicit or aggravate sweating, but psychological/psichiatric disturbances are only rarely the cause of the disorder.

Manifestations of Primary Hyperhidrosis

Facial Hyperhidrosis
Sweat pouring down from the forehead in conditions of stress can be very distressful, inducing the patient to think that others may consider him/her nervous and insecure.
Palmar Hyperhidrosis
Excessive sweating of the hands is, generally, by far the most distressing condition. The hands are much more exposed in social and professional activities than any other part of our body. Many individuals with this condition are limited in their choice of profession, because unable to manipulate materials sensitive to humidity (paper etc) or reluctant to shake hands; some patients arrive to the point to avoid social contact. The degree of sweating varies and may range from moderate moisture to dripping. Most patients notice that their hands not only feel moist, but also cold.
Axillary Hyperhidrosis
Also hyperhidrosis of the armpits can be embarrassing causing large wet marks and sometimes a white halo of salt from sweating on the cloths.
Plantar Hyperhidrosis
Other locations
Less frequently, it is located only to the trunk and/or the thighs. Other patient are suffering from copious sweating in the face.
* Many individuals suffer form a combination of the above cathegories.
* Sweating can appear suddenly or manifest itself more continuously.
* It can be elicited by high outside temperatures or emotional stress, or appears without any obvious reason.
* Generally, it worsens during the warm season and gets better during winter.

Treatment

In secondary hyperhidrosis, the underlying condition should be treated first. Patints on hormonal therapy for prostatic cancer (castration, LHRH-analoges) with disturbing sweat attacks can get relief by the administration of antiandrogens (ciproterone acetate).

In patients with primary hyperhidrosis or for symptomatic treatment of heavy sweating in patients with secondary hyperhidrosis, not treatable otherwise, the following methods have been adopted. In psychiatric patients with hyperhidrosis, successful treatment this symptom often reduces the tendency towards emotional distress.

ANTIPERSPIRANTS
Usually recommended as the first therapeutic measure. The most effective agent appears to be alluminum chloride (20-25%) in 70-90% alcohol, applied in the evening 2-3 times/week. Generally, this treatment is sufficient in cases with light to moderate hyperhidrosis but has to repeated regularly.
IONOPHORESIS

Iontophoresis is a technique that uses a weak DC current, applied to the part of the body to be treated, to carry drugs through intact skin. In hyperhidrosis, simple tap water iontophoresis is used, normally without adding any active substances, to treat patients who have not achieved satisfactory results with antiperspirants.

How does it work:
The mechanism of action is not fully understood, but it is thought that the electrical current produces a minimal thickening surface layer of the sweat ducts, so that the perspiration is reduced or even blocked. In addition, the sensitivity of the sweat receptors that respond to stimulation of the gland seem to become impaired.

Method:
The treatment consists in placing the hands and/or the feet in flat containers which are partially filled with water and have electrodes and cables connected to a DC generator. The intensity of the current is increased with a knob until a slight tingling sensation is felt. For the armpits and other parts of the body, there are special electrodes available(electrode pads of absorbent material) that have to be soaked in water before use.

Tap water seems to be an ideal conducting fluid, better even than saline for the purpose of inhibiting the sweat glands, despite saline being a better conductor. Only exceptionally, in areas with tap water of extremely low conductivity (almost no mineral content), half a teaspoon of bicarbonate can be added to 1 liter of water in order to improve conductivity.

Each treatment lasts around 15-30 minutes. In the beginning, it should be performed daily or every 2 days over a period of 1-2 weeks until the sweating stops. The duration of dryness varies from person to person and can last for several days, up to 3-4 weeks. Once the moisture reappears, a maintenance treatment should be carried out. Some patients undergo treatment regularly once a week as a preventive measure.

Continuous DC - Pulsed DC:
The classical iontophoresis treatment is performed with direct current (DC) of constant intensity. On feet and hands this has been for decades and still is a very reliable treatment for many patients. Under certain circumstances this type of current may cause unpleasant sensations or even pain at higher current levels, maybe before reaching a level necessary for effective treatment. This happens particularly in areas where the skin is very sensitive (armpits, face, etc.) or when there are small skin lesions. Some people do not tollerate the treatment because generally more sensitive, such as children.
Therefore, devices have been developed that deliver direct current in intermittent pulses of certain frequency. This type of current is much less perceived and therefore, at the same amperage, far better tolerated. The patient accepts a higher amount of energy and can therefore expect a much better effect. Unfortunately, this advantage comes at a higher price.

ionoforesi per iperidrosi palmare
Iontophoresis for palmar hyperhidrosis
ionoforesi per iperidrosi plantare
Iontophoresis for plantar hyperhidrosis
Hidrex
Idromed PS
Examples of different devices

Iontophoresis and Drugs:
In medicine, the principle of iontophoresis is often used to get pharmaceutical substances through the skin with the help of electrical current, aiming to achieve high concentrations and a maximum effect of the drug locally, and minimizing the side effects in distant areas. The method is particularly useful in combating local painful and inflammatory conditions. Devices dedicated to drug-iontophoresis have a weaker output (5-10 mA). Iontophoresis for the treatment of hyperhidrosis should deliver at least 25-35 mA continuous DC and/or 15-25 mA for pulsating DC. If the treatment fails to yield acceptable dryness at highest tollerable current levels, a tiny dose of an anticholinergic drug (eg atropine) may be added to the water. However, such a measure should be carried out only under medical supervision in order to avoid toxicity by overdosing.

Equipment, specifically designed for the treatment of hyperhidrosis at home or in the physician's office, is available from specialized online suppliers (e.g. Excessive sweating solutions USA, UK, Germany).

DRUGS
There are no specific drugs available against profuse sweating. Psychotropic (mostly sedative) and/or anticholinergic drugs are often tested but show usually too many side-effects before any noticeable result can be achieved. Hence, they are, as a rule, not recommended. In those few cases who suffer from profuse sweating on the trunk (but not the extremities), a low dose of anticholinergic agent can slightly alleviate the symptoms without rendering life unsupportable from side-effects (dry mouth, accomodation difficulties of the eyes, etc), but a dosage necessary to normalize the amount of sweating will rarely be tolerated.
BOTULINUM TOXIN
A family of toxins produced by a bacteria known as Clostridium botulinum. This toxin is one of the most lethal poisons known, interfering with the effect of the transmitter substance acethylcholine at the synapses (the contact point of a nerve ending with another nerve cell or a muscle) and leading to progressive paralysis of all muscles in the body, including the respiratory muscles. In extremely low doses, botulinus toxin has been adopted in cases with localized muscle hyperactivity (lid spasms, torticollis, etc), resulting in a reduction in transmitting impulses to the muscle. Initial reports have been published regarding the use of botulinum toxin in hyperhidrosis. It seems to work adequately in axillary hyperhidrosis, lasting for 6-12 months depending on the dosage (0.5-1.0 Units/cm2;). A drawback are the costs of this treatment which has to be repeated at regular intervals, but the side-effects seem to be negligible if dosages are kept low.
SURGERY
Patients with axillary hyperhidrosis who are unresponsive to medical therapy can be effectively treated by excision of the axillary sweat glands. If sweating extends beyond the hairy portion of the axilla, several skin incisions may be needed, sometimes resulting in formation of hypertrophic and/or constrictive scars.
- The principle of sympathectomy is to interrupt the nerve tracks and nodes (ganglia) which transmit the signals to the sweat glands. Basically, this can be achieved for all locations in the body, but only the nerve nodes responsible for the sweat glands of the palms and the face are accessible without the need for a major surgical procedure. Today, the treatment of choice for moderate to severe palmar and facial hyperhidrosis (but also axillary, especially if combined with palmar sweating), consists in a surgical procedure known as Endoscopic Thoracic Sympathectomy. This minimal-invasive endoscopic technique has been developed in recent years in a few hospitals in Europe, superseeding Conventional Thoracic Sympathectomy, a very traumatic procedure performed in the past. The endoscopic technique is very safe, if performed by a surgeon experienced in this type of procedure, and leads to definitive cure in nearly 100% of patients, leaving only a minimal scar in the armpit.
- Individuals with combined hyperhidrosis of the palms and soles have a good chance to improve the sweating of their feet after an operation aiming to suppress sweating of the hands.
Isolated plantar hyperhidrosis can nowadays be successfully treated by Retroperitoneoscopic Lumbar Sympathectomy, a video-endoscopic procedure with very limited side-effects which requires only an overnight hospital stay and a few days recovery. Open abdominal procedures should be considered obsolete.
- Diffuse hyperhidrosis of the trunk or general sweating of the whole body cannot be treated by surgery.
OTHER TREATMENT OPTIONS
In the experience of the author, many patients, disappointed by the treatment offered by their doctors, have tried different methods of alternative therapy including homoeopathy, massage, acupuncture and phytotherapeutic drugs, in almost all cases without noticeable improvement.
There are no systematic studies on this method. Few patiens have tried it, reporting poor results on palmar hyperhidrosis.
Very limited effect in the absolut majority of patients. Psychological problems are in most cases a consequence of hyperhidrosis, not the cause. Hence, psychiatric or psychopharmacologic therapy cannot cure this disorder, at most it may help the patient to accept living with the problem.

Recommended Reading:

Inquiries, suggestions or communications to the author:

e-mail: summit@parsec.it
Ivo Tarfusser, MD
Via delle Corse 52
39012 Merano (BZ), Italy
Tel +39 335 24 16 86, +39 0473 237312
Fax +39 0473 236409



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2003-02-06