Hyperhidrosis

There are two main types of hyperhidrosis; primary (focal) and secondary (generalized) with both involving sweating that is beyond that which is required by the body to regulate heat.

The more common type of hyperhidrosis is primary hyperhidrosis which can affect the armpits (axillary), hands (palmar), feet (plantar), face/neck/head (cranio-facial) or groin (inguinal). The most common of these is axillary.

Secondary hyperhidrosis is less common, affecting the whole body and usually caused by another underlying medical condition such as the menopause, infection, diabetes or hyperthyroidism. When the illness is treated, the excessive sweating usually stops. It can also be caused by a side effect of a medication being taken to treat a medical condition.

It is thought to be caused by a ‘hyperactive autonomic system’ or an ‘overactive thermoregulation system’ so therefore increased cholinergic activity on the eccrine sweat glands and is thought to be linked to the thermoregulatory centre of the hypothalamus and sympathetic nervous system.

The excess sweating starts around or soon after puberty.

Common features of primary hyperhidrosis are: It usually begins in childhood or adolescence and tends to run in families

• You rarely sweat at night
• You sweat from particular parts of your body e.g. your armpits and your hands on both sides.
• You sweat at least once per week
• You find sweating impairs your daily activities.

According to the International Hyperhidrosis society (IHHS), it is estimated that about 5% of the population has some form of hyperhidrosis. According to the British medical Journal it is reported that of the hyperhidrosis sufferers, 73% suffer from axillary hyperhidrosis, followed by 45.9% in the hands, 41.1% in the feet, 22.8% in the scalp and 9.3% in the groin (Benson et al 2013).

Sweating is the human body’s way of keeping cool, known as thermoregulation. Fluids or sweat are secreted through sweat glands in the skin, which then evaporates, having a cooling effect. The 2 main types of sweat glands are eccrine sweat glands and apocrine sweat glands. Eccrine sweat glands are the major sweat glands of the body, found in virtually all skin. They produce a clear, odorless substance, consisting primarily of water and NaCl. Apocrine sweat glands are found in places like armpits and the groin area and are least responsible for thermoregulation and most responsible for body odour (BO). Apocrine sweat glands periodically secrete an oily fluid (containing pheromones and other lipids) directly into the canal of the hair follicle. Excessive secretion from these glands contributes to the condition of bromhidrosis. Both eccrine glands and apocrine glands are stimulated by the sympathetic nervous system during anxiety, stress and exercise but in the eccrine sweat glands, the neurotransmitter is acetylcholine (whereas in the rest of the SNS, the neurotransmitter is adrenaline).

A normal adult will sweat from the sweat glands up to a maximum of 2-4 litres per hour or 10-14 litres per day dependent on exertion or hot weather. In someone with hyperhidrosis the thermoregulation process is hyperactive and can cause them to produce 4-5 times more sweat than is required to enable them to cool down.

According to the experts in the field (NICE guidelines), the recommended order of management is as follows:

Lifestyle changes. It is advised that patients avoid things that can make sweating worse such as smoking, alcohol consumption, caffeine and spicy foods. Wearing cool clothes or clothes made from natural fibres. It is important to pay extra attention to personal hygiene It is important to reduce stress, tension and anxiety to reduce stimulation of the sweat glands.

Stronger anti-perspirants. Regular anti-perspirants are often not adequate to control excess sweating so there are some stronger versions that are available that contain the active ingredient aluminium chloride. Anhydrol Forte (roll on), Odaban (spray) and Driclor (roll on) are sold in most chemists. Aluminium chloride deodrants should be applied at night to dry skin. There are also aluminium-free antiperspirants available to buy aswell. Botox – Injections of botulinum toxin (type A) into the skin has been shown to be a very effective treatment for primary hyperhidrosis by blocking the signal that fires the sweat glands. Two brands of Botox in particular have been licensed especially for axillary (armpit) hyperhidrosis. Effects start within the first week after treatment and last for an average of seven months before further injections are required. Side effects are rarely troublesome. Oral medicines prescribed to reduce sweating are from a group of drugs called anticholinergics. They work by blocking acetylcholine, the chemical at the end of the nerve which triggers the sweating. As they are taken orally they can unfortunately have side effects on the rest of the body such as constipation & dry mouth. Some companies are working on developing anticholinergics in the form of creams or wipes (e.g. Qbrexxza®) so they can be used directly in the area of hyperhidrosis without the side effects. Iontophoresis is the passage of a weak electric current through the skin of the hands and feet while they are immersed in a water bath. The electrically charged particles block the activity of sweat glands. Iontophoresis is considered a safe and effective and many people can do this at home with the correct equipment. There is the option of adding an anticholinergic medication to the water where iontophoresis alone isn’t effective. Sweat gland destruction procedures. There are several procedures that are effective in destruction of the sweat glands without the need for surgery. These include: microwave energy (e.g. miraDry®), radiofrequency, laser and focused ultrasound. Surgery can provide a permanent solution but the side effects can be serious. Surgery is usually considered when other methods of treatment have not worked. The different types of surgery include curettage & excision where the sweat glands are removed Endoscopic thoracic sympathectomy (ETS) where a portion of the sympathetic nerve trunk is destroyed.

Botox works by locally blocking the autonomic sympathetic cholinergic nerve fibres innervating the sweat glands. In other words, botox blocks the sweat glands from firing!

The most common area to have treated are your armpits, followed by your hands, feet and face.

No deodorant for 24 hours prior to treatment Ensure you are rested without hot drinks or exercise for 30 minutes prior to treatment Clean, shave and dry the armpit before treatment.

Prior to your treatment you will have a thorough consultation with your healthcare practitioner where all your questions are answered and you are assessed for your suitability to proceed.

To be diagnosed as focal or primary axillary hyperhidrosis, at least 2 of the following characteristics have to be present in an otherwise healthy patient: Bilateral and symmetrical involvement Impairment in daily activities Age of onset tends to be around adolescence and tends to run in your family Rarely sweat at night

Ax of sweat stain: Mild sweat stain 5-10cm still confined to armpit Moderate 10-20cm still confined to armpit Severe 20cm reaching the waistline.

The involved area is mapped out using a markerpen/white pencil and the enclosed area is then divided into a grid pattern. Some practitioners may use the Starch-iodine test to highlight the hyperhidrotic areas of the armpit. Botox is then injected into each armpit using a tiny needle. Approximately 10-25 injections are carried per armpit. Because a very fine needle is used, most patients find that there is only mild and temporary discomfort. The entire treatment usually takes no longer than 30- 45 minutes. Most patients have a perceived benefit within 1-2 weeks and have a duration of relief from 6-18 months.

In the mostpart, Botox provides a 75-100% reduction in sweating in most patients. Clinical research data shows that Botox provides a 50% or greater reduction in sweating for a duration of approximately 7 months in the majority of people (Naumann et al 2003). The response to treatment is effective and predictable with a very high patient satisfaction rate.

You will probably not need to have another treatment for at least 6 months, normally around 7-8 months. Following repeated treatments, the effects tend to last for a longer period of time. If you have a good initial result, please note that, as recommended by the manufacturers of the treatment, we aim not to perform any “top-up” treatments within a 3 month period following your treatment. It is not recommended to have more than 3 hyperhidrosis treatments with Botox per year and no less than 4 months apart.

Side effects of Hyperhidrosis treatment are rare – indeed it is one of the safest cosmetic procedures available. Side effects (fewer than 1% experience side effects): Compensatory hyperhidrosis Injection site pain

• Hot flushes
• Body odour
• Pruritus
• Rash

Studies have not been performed on women who are pregnant or breastfeeding. Although treatments are not thought to be dangerous, treatment is best avoided during this time. If you have any diseases, involving nerve damage or muscle weakness, Hyperhidrosis treatment is not recommended. It is also important to let your Doctor know if there is a family history of such diseases – for example Myasthenia Gravis or if you have previously suffered from Bell’s Palsy. Patients who are currently being treated with aminoglycoside antibiotics or spectinomycin should wait until they have completed their course of treatment, and anyone who has had an allergic reaction to human albumin should not have Hyperhidrosis treatment.

Yes but availability is extremely limited and waiting lists are long, hence the growth in the amount of patients seeking help from private clinics.

Further information regarding hyperhidrosis can be found on the following websites www.hyperhidrosisuk.org www.sweathelp.co.uk www.sweathelp.org www.nhs.uk/conditions/excessive-sweating-hyperhidrosis/ www.cks.nice.org.uk/hyperhidrosis