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