What are medical treatment options for hyperhidrosis?
Through a systematic evaluation of causes and triggers of excessive sweating, followed by a judicious, stepwise approach to medical treatment, many people with this annoying disorder can achieve improved quality of life. The decision on initial treatment depends upon the severity of the condition and the anatomical areas that are affected.
The approach to treating hyperhidrosis generally proceeds as follows:
- Over-the-counter antiperspirants: Patients usually try home remedies like these first because they are readily available. Antiperspirants containing aluminum chloride (for example, Certain-Dri) may be more effective when other antiperspirants have failed. So-called "natural" antiperspirants are often not very helpful for patients.
- Prescription-strength antiperspirants: those containing aluminum chloride hexahydrate
- Iontophoresis: a device that uses a direct current to drive ions into the sweat gland using tap water occasionally mixed with aluminum ions or other substances
- Oral medications: from the group of medications known as anticholinergics, which reduce sweating
- Topical medicated pads: pads impregnated with anticholinergic medications for use in the armpits
- Botox (botulinum toxin): approved in the U.S. by the Food and Drug Administration (FDA) for treating excessive axillary sweating
- Microwave destruction: a device destroys the sweat glands, purportedly causing minimal damage to other tissues
- Surgery: paraspinal sympathectomy, or interruption of certain nerve pathways, as a last resort
Aluminum chloride hexahydrate
When regular antiperspirants fail, as they often do, to remedy hyperhidrosis, most doctors start by recommending aluminum chloride hexahydrate (Drysol, various generics), a prescription-strength version of aluminum chloride. It is applied just before bedtime seven to 10 nights in a row, then roughly once a week as a maintenance medication. The aluminum salts in this preparation collect in the sweat ducts of the patient and block them. Over time, the excessive perspiration may diminish to such an extent that no further treatment is needed. This method works reasonably well for many patients whose problem is excessive underarm sweating, but it's not satisfactory for most of those with clammy palms and sweating of the soles of the feet.
The main side effect with aluminum chloride is irritation, which can sometimes, but not always, be overcome by reducing the frequency of use or applying anti-inflammatory medications such as lotions containing hydrocortisone.
Iontophoresis was introduced over 50 years ago to treat excessive sweating. Its exact mechanism of action is still unclear. The procedure uses water to conduct an electric current to the skin, which combats the production of sweat. The current is applied typically for 10-20 minutes per session, initially with two to three sessions per week followed by a maintenance program of treatments at one- to three-week intervals, depending upon the patient's response. Iontophoresis treatments sound painful but in fact are not.
Patients purchase devices for this treatment through a doctor's prescription. There are three iontophoresis devices that are registered with and cleared by the U.S. FDA; the R.A. Fischer and the Hidrex USA devices require a prescription, whereas the Drionic device is available without a prescription. They work best on palms and soles but can be adapted for use in the underarms. Medical insurers sometimes cover the cost.
Oral anticholinergic drugs such as glycopyrrolate (Robinul), oxybutynin, and propantheline bromide can be quite effective for this condition, but they can produce side effects like dry mouth, insomnia, and blurred vision. The dosage should be titrated carefully.
Topical anticholinergic pads
Recently, a new topical treatment using glycopyrronium tosylate impregnated gauze pads (Qbrexza) has received approval for the treatment of axillary (armpit) hyperhidrosis.
Botulinum toxin (Botox), a muscle poison much in the news as a cosmetic treatment for wrinkles, has actually been used in many areas of medicine for some time, such as in the treatment of muscle spasms and certain types of headaches. Its latest medical use is for treating excessive underarm sweating.
Botox is injected into tissues of the armpit or hand. The drug works by inhibiting the release of acetylcholine, which is the chemical that activates sweat glands. This may produce approximately six months of relief from sweating. The injections are uncomfortable, but use of a very small needle minimizes discomfort.
Now that this treatment option has received FDA approval, many health insurers are providing coverage for the injections and the Botox itself, which is quite costly.
Currently, the FDA has not approved Botox for treating sweating of the palms and soles of the feet, though some physicians are administering it as an off-label use, with some success. Drawbacks of using this treatment for the palms and soles are pain, requiring nerve blocks to numb the hands in order to make the injections tolerable, and the potential for temporary muscle weakness.
Microwave, laser, and ultrasound destruction
These new techniques produce energy that presumably destroys sweat glands while preserving other tissues. Currently, only the armpits seem to be appropriate treatment sites. Treatments occur in a doctor's office and in recent studies have been accompanied by local swelling and irritation as well as a variety of other relatively minor side effects. Sweating seems to be significantly decreased for a time with these treatments. How these would be used in other anatomical areas aside from the armpits is not clear.