Cosmetic Medicine | Dr. Enrique Etxeberria, Plastic Surgery in Bilbao

Hyperhidrosis

Cosmetic Medicine - Hyperhidrosis - Hyperhidrosis

Hyperhidrosis

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Hyperhidrosis is excessive perspiration of different parts of the body (armpits, palms of the hands, feet…) and can represent a serious problem for some people because it gives them a complex and obstructs their relations, as excessive sweating can denote nerves or insecurity and can also be interpreted as a lack or hygiene without this being the case.  It consists of excessive sweating produced by a failure in the sympathetic nervous system (part of the autonomous nervous system) making the body produce more sweat than it needs to regulate body temperature.

This disorder tends to begin in childhood or puberty and normally, if it is not attended to correctly, it lasts a lifetime.  It is estimated that 1% of the population suffers from primary hyperhidrosis; it affects men and women equally. Up to 40% of those affected has another family member with the same disorder, and it is therefore a hereditary disorder.

In addition, there can be primary or secondary hyperhidrosis: the former can begin at any time of life and its background is purely hyperhidrosis per se, unlike the latter, secondary hyperhidrosis, which as its name indicates, can be due to disorders of the thyroid or pituitary gland, infections, diabetes mellitus, tumours, menopause or certain drugs.

What types of hyperhidrosis are there?

Hyperhidroses can be generalised (affecting the entire body surface) or localised (affecting circumscribed areas). In addition they can be of unknown origin (essential) or due to a cause that can be identified (pathological).

But the most common hyperhidroses are idiopathic and localised, to the armpits, hands and feet and face. Idiopathic or localised essential hyperhidrosis begins in childhood/adolescence and affects 0,6%-1% of the population. This persists for a few years and sometimes there is a tendency to spontaneous improvement at the age of around 25. There is often a family history.

TYPES OF TREATMENT

•    Aluminium chloride solution (hexahydrate).
Consists in the application of antiperspirant solutions with a higher concentration of aluminium chloride. It can be effective for axillary hyperhidrosis alone, and to a lesser degree for palmar and plantar hyperhidrosis.

•    Iontophoresis.
Consists in passing a low voltage electrical current through water or dampened pillows, which makes the superficial proteins of the skin coagulate and partially block the sweat glands.

•    Oral medication.
There are diverse systemic pharmacological treatments: anticholinergic drugs such as propantheline bromide which has multiple side effects such as dry mouth, drowsiness, vertigo and blurred vision; tranquilisers and sedatives such as clonazepam or diazepam and others such as calcium antagonists (diltiazem). In general, these drugs are not prescribed due to the potential side effects they can cause. Within the topical pharmacological treatments there are two groups: anticholinergic drugs such as glycopyrronium bromide and astringents and tanning preparations.  Within these are aluminium chloride, glutaraldehyde or salicylic acid.  Usually, these are the ones indicated during the first consultation.

•    Thoracoscopic Sympathectomy.
Is an operation which is performed with general anaesthetic.  To access the sympathetic system an artificial pneumothorax is required, in other words, inserting air into the lungs so that they lift up and away from the nerve ganglia.

•    Other therapies.
Being overweight increases excessive sweating and therefore it is advisable to visit an endocrinologist in order to be put on an adequate diet.  Coffee and smoking increase sweating and it is therefore better to avoid them. For non-organic hyperhidrosis it is necessary to attend a psychologist for therapy which can help overcome problems of self-esteem and insecurity, amongst others, which can be the cause of this illness. Oriental relaxation therapies such as Yoga, Zen, and Shiatsu can help to overcome the stress caused by being covered in sweat.

•    TBotulinum Toxin Type A.
Its effect is due to a selective blockage in the action of the acetylcholine on the eccrine glands.  By so doing there is a reduction in the function of said glands, and therefore a reduction in the production of sweat where this drug is administered . Selective application in the areas of greatest perspiration enables it to act only in the areas that present most hyperhidrosis, and thereby avoid potential systemic side effects.

The use of botulinum toxin as a weapon against excessive sweating or hyperhidrosis, was discovered in 1994. And although experts agree on the effectiveness of this treatment, they also do so in noting its most worrying side effect: the frequency of recurrence within four to six months after the implementation of the substance in the areas to be treated.

What therapeutic guidelines can we follow in the event of localised hyperhidrosis?

The initial or first line treatment is a solution of aluminium chlorohydrate hexahydrate at 20-25% in solution of ethanol for axillary hyperhidrosis, solution of glutaraldehyde at 2% for palmar hyperhidrosis and glutaraldehyde at 10% for plantar hyperhidrosis.  The mechanism for action appears to be the occlusion of the sweat gland duct.  It should be applied at night and on dry skin.
As a second option are anticholinergic drugs or iontophoresis.  If these fail there are other options such as botulinum toxin.  The latter irreversibly blocks the liberation of acetylcholine, thereby deactivating cholinergic transmission, but subsequently new synapses are created and therefore the effect is temporary. In the armpit, the intradermal injection is well tolerated, but on the palms of the hand a regional anaesthetic is required.  It has been approved for use in the armpits, and can be administered in a hospital environment if the doctor deems this opportune.  On the palms of the hands this continues to be for compassionate use and permission must be sought from the Ministry, which tends to grant it without a problem.  The latest therapeutic alternative is a sympathectomy which can currently be performed by videothoracoscopy.

INDICATIONS

Patients who present excessive perspiration in the armpits and on the hands.

TREATMENT

Injection at very low dosage of the toxin, with a very fine needle and in small drops, and superficially, in the area to be treated. The intradermal administration of botulinum toxin A is effective for the treatment of axillary and palmar hyperhidrosis and has no serious side effects. The treatment is performed with local anaesthetic and hospitalization is not required.

EFFECTIVENESS OF THE TREATMENT

The effects of the treatment begin to be noticed between two to four days after the injection and the sweating disappears completely within a week. The duration of the treatment is approximately six months, after which it must be repeated in order to continue controlling the pathology.
On average, the effect lasts between 4 and 9 months, depending on the metabolism of the person affected. The results are evident between the second and fourth day following application. The treatment is performed approximately once or twice a year.

CONTRAINDICATIONS

It is contraindicated in pregnancy and breastfeeding. In patients treated with anticoagulants and those who suffer from coagulopathy. If there is an infection in the area to be treated. In the event of Myasthenia Gravis, Eaton Lambert Syndrome or Amyotrophic Lateral Sclerosis.