Excessive Sweating Axillary Hyperhidrosis Palmar Hyperhidrosis Scalp Hyperhidrosis; Hyperhidrosis Bromhidrosis

What is Hyperhidrosis?

Hyperhidrosis—otherwise known as excess sweating—is often underdiagnosed and undertreated. Dr Prashant Murugkar focuses on the main diagnostic features and management of hyperhidrosis.

What is Bromhidrosis?

Bromhidrosis is a condition often associated with Excessive Sweating, but sometimes occurring on its own, that relates to Foul Body Odour that is caused by the decomposition of the sweat gland secretions by bacteria normally present on the skin.

Are there different types of Hyperhidrosis or excessive sweating?

Hyperhidrosis can be generalized by the area involved or classified as primary or secondary based on the cause.

In primary hyperhidrosis, the cause for the excessive sweating is not known; in secondary hyperhidrosis, the primary disorder—such as pituitary or thyroid dysfunction, diabetes mellitus or menopause—is responsible for the hyperhidrosis.

Primary axillary hyperhidrosis is the most common location for excessive sweating in patients and often presents along with palmo-plantar hyperhidrosis.

What is the mechanism of Hyperhidrosis or Excessive Sweating?

Sweating is controlled by emotions through the limbic system and the thermo-regulatory center in the hypothalamus. These affect the post-ganglionic sympathetic outflow of the para-spinal sympathetic chain. While the definitive cause of this condition is yet to be elucidated, most evidence points to a hyperactive autonomic system.









How do I know that I have Axillary Hyperhidrosis?

The patient will often give a history of focal, visible, and excessive sweating that has come on without any apparent cause over the last six months. Often, he or she has a family history of similar problems.

To be diagnosed as primary axillary hyperhidrosis, at least two of the following characteristics have to be present in an otherwise healthy patient:

• bilateral and relatively symmetric involvement

• impairment in daily activities

• age of onset < 25>

• cessation of focal sweating during sleep.

Are there grades of Axillary Hyperhidrosis or Excessive Sweating in the Armpit?

Assessment of sweat stains on shirts or blouses can give a clue as to the severity of the hyperhidrosis. A mild sweat stain, 5–10cm, still confined to armpit; moderate, 10–20cm, still confined to armpit; severe, 20cm, reaching the waistline.

Minor (starch-iodine) test: this is a commonly used test, but it can be rather messy. A 2% iodine solution or 10% povidone iodine antiseptic solution is applied to both the armpits and allowed to dry; corn-starch powder is then brushed on to this area. The test is positive when the light-brown colour turns dark purple as an iodine-starch complex forms in the presence of sweat. The area can then be photographed as a preoperative record of the affected area and also to gauge the response to treatment.

Despite nearly 1–2 % of the population being affected, there is extraordinarily little awareness of this problem and the resources available for its solution.

Can I get treatment for Hyperhidrosis, Bromhidrosis or Excessive Sweating on the NHS?

There are no nationally agreed guidelines for the management of hyperhidrosis or Bromhidrosis in the NHS.









Are there any treatments for Hyperhidrosis, Bromhidrosis or Excessive Sweating?

There are several levels of treatments available going from Over-the-Counter treatments available at the pharmacy like Antiperspirants, Glycopyrrolate wipes, Water Electrophoresis, Botulinum Toxin Injections (Botox), Microwave reduction of Sweat Glands using MiraDry, Surgical options like Curettage of sweat glands using liposuction cannula and finally Sympathectomy.

What is QBREXZA?

QBREXZA® (glycopyrronium) cloth is a pre-moistened, medicated cloth towelette that comes in individually wrapped packets. Apply QBREXZA once a day to reduce excessive underarm sweating.

Which Antiperspirants are best for Hyperhidrosis, Bromhidrosis or Excessive Sweating?

Antiperspirants can be roll-on gels or powders that bring about a reduction of eccrine sweat production by physical obstruction of the ductal openings by the metal salts from the chemicals used.

The most common ingredient is 20% aluminum chloride hexahydrate, which is available as Anhydrol Forte or Driclor. This should be applied every night after carefully drying the skin for 5–7 days, or until the maximum benefit is achieved. Thereafter, the frequency of application can be reduced to once or twice a week.

It is important to wash off the medication in the morning and some even suggest to neutralize the area with an application of baking soda. If the patient develops pain or has a rash, interruption of treatment and application of a topical steroid such as 1 % hydrocortisone cream can reduce the inflammation. Once the this has settled, the antiperspirant, such as driclor can be restarted.

Can Botulinum toxin type A help with Hyperhidrosis, Excessive Sweating or Bromhidrosis?

Botulinum toxin type A—Botox, Bocouture, Azzalure or Dysport—is a purified neurotoxin derived from clostridium botulinum. It works by blocking the release of acetylcholine at the neuro-muscular endplates of the sympathetic cholinergic nerve fibers of the sweat glands.






After mapping the involved area by clinical observation or the minor test, an outline is drawn out with a skin marking pen. The enclosed area is then divided into a grid pattern with each of the grid squares being approximately 1–2cm. This is because the dispersion of the botulinum toxin when placed intradermally is about 1–2cm.

Under antiseptic precautions using a 30 gauge needle, 50 U (of a 100 U/4.0 mL dilution) of Botox is injected intradermally (ensuring that a bleb is raised) into each axilla.

Most patients have a perceived benefit from the treatment within 1–2 weeks and have duration of relief ranging from 6–18 months.

Is Botox or Botulinum Toxin Type A injections safe for Excessive Sweating or Axillary Hyperhidrosis, Hyperhidrosis or Bromhidrosis?

The main contraindications for the use of Botulinum Toxin Type A, include an allergy to any ingredient of the formulation; patients with rare neurological diseases such as myasthenia gravis, Eaton Lambert syndrome; presence of infection at the site;  lactating mother, or pregnancy.

Fewer than 1% of the patients experience any kind of side-effects. The most common are compensatory hyperhidrosis (an increase in non-axillary sweating), injection site pain, hot flushes, pruritus and rash.

What is Sympathectomy for Hyperhidrosis?

In sympathectomy, the fourth thoracic ganglion of the sympathetic nervous system chain that controls the nerve supply to the sweat glands affected in axillary hyperhidrosis is disconnected using an open or endoscopic approach to get relief from axillary hyperhidrosis. However, it is associated with a high incidence of compensatory hyperhidrosis from other areas of the trunk and is more suited to treat palmar hyperhidrosis.

Are there any medicines I can take for Excessive Sweating or hyperhidrosis?

The use of anticholinergic drugs—propantheline bromide and glycopyrrolate work by blocking the acetylcholine secretion and can offer relief from the symptoms. However, the incidence of adverse symptoms, such as visual blurring, dryness across mucosal surfaces and constipation reduces their utility when given systemically. Glycopyrrolate has therefore been delivered topically using iontophoresis.







What is Iontophoresis for Excessive Sweating of the Palms or Palmar Hyperhidrosis?

Iontophoresis involves an application of a direct electrical current across the skin. The mechanism of action of this modality is uncertain. While iontophoresis pads for axillary application are available, the real utility of this modality is in treating palmar and plantar hyperhidrosis.

What other surgical treatments help with Axillary Hyperhidrosis or Excessive Armpit Sweating?

Surgery of the sweat glands is another treatment of this condition and can include — retrodermal curettage (essentially scrapping the sweat glands away) or liposuction to remove the sweat glands from the undersurface of the axillary skin are also effective solutions.

What is MiraDry?

This is a treatment that uses Microwave radiation to reduce the activity of the Axillary or Armpit sweat glands. There seems to be a permanent reduction of the sweat glands following one or two treatments, this is associated with dryness that can be permanent or long lasting/

What is the cost of Botox for Under Arm Sweating?

At Reforme Medical the following are the charges for Sweat Reduction Injections

Scalp Hyperhidrosis from £375 – 600 as per severity

Axillary hyperhidrosis from £400

Groin hyperhidrosis injections £450

Hands or Feet hyperhidrosis £800 – 900


Dr Prashant Murugkar MBBS, MS, MCh, DNB, MRCS(Eng.) Plastic surgeon