Anxiety may cause one to sweat but excessive sweating surely can lead to anxiety. Hyperhidrosis (the official term for this condition) is causing an estimated 3 percent of the U.S. population (that's almost 8 million individuals) to do both! Incessantly moist skin interferes with business and social interactions, wreaks havoc with one's quality of life and may even cause depression. Yet therapy is now more effective than ever and offers the opportunity.

The Science of Sweat

Everyone sweats. After all, sweating is Nature's way of controlling core body temperature and preventing overheating.

Four million sweat glands are scattered across the body. The majority of these (75%) are "eccrine" sweat glands, which are found clustered on the soles of the feet, palms, forehead, cheeks, and needless to say, the armpits.

Sweat is mostly water with minute amounts of urea, salt, sugar and ammonia. Two types of sweat glands exist. "Classic" sweat is produced by the eccrine sweat glands distributed over the entire body. Unconscious triggering of the sympathetic nervous system releases the messenger enzyme acetylcholine, in turn causing the eccrine glands to release sweat onto the surface of the skin.

Eccrine sweat is initially odorless, unless tainted by the stray problematic spice, garlic, alcohol, metabolic disorder or medications, which may transiently leach into the sweat. Since sweat itself lacks fragrance, it is really the presence of sweat that begins the cascade of odor-causing events.

Sweat softens epidermal keratin, a move which itself can create smell. Bacteria feed upon stale eccrine sweat and softened keratin worsening the rancid smell. Macerated skin (moist, white, often tender skin) tends to develop in body fold areas. Protected hot, damp skin is ripe for allowing further growth of bacteria as well as yeast that further complicate the malodorous situation.

Apocrine glands account for the remaining 25% of sweat glands. They have a limited distribution, located strictly around the breasts, in the axillae and the groin. A few apocrine elements also exist surround the eye and ear areas. These glands produce only a limited amount of thick fluid, so do not directly contribute to hyperhidrosis.

Their primary function is to generate pheromones. While advertisers may leave you thinking pheromones exist solely to romantically attract a mate, in reality they make that "personal scent" that most of us find displeasing. They are primarily responsible for causing body odor, medically known as bromhidrosis.

Apocrine sweat is triggered by a different neurotransmitter - catecholemines. Corynebacterium normally residing upon the skin break down apocrine sweat. The result of the bacteria digesting and breaking down the secretions are strong smelling short-chain fatty acids. The more bacteria present or the higher the level of apocrine sweat production, the worse the offensive odor can become. Because the eccrine and apocrine sweat glands are not "turned on" by the same chemical signal, therapy for hyperhidrosis which targets the eccrine sweat gland is unlikely to affect the apocrine glands, making daily odor control a continued necessity.

A rise in core body temperature expected to produce sweating occurs in response to:

• Emotion
• Exertion
• Chemical messages (whether true or false) originating from the brain
• Hormones

For the patient with hyperhidrosis, the problem is not the size or number of eccrine sweat glands but their hyperactivity, at times in the absence of any of the expected triggers noted above. Two forms of hyperhidrosis exist, primary and secondary.

The primary form affects localized areas - the palms, the soles, underarms and forehead. It most commonly begins during childhood or just after puberty. There is frequently a family history, too. Primary hyperhidrosis is bilateral and symmetrical. If one palm is affected, so is the other. It can't be just one side of the forehead that sweats in excess, it's the entire region. Anxiety, heat and exertion are common triggers. It is unlikely that these patients will experience problems with sweating while asleep.

We still do not fully understand why some individuals are afflicted by this condition. While hyperhidrosis can be the result of simple genetics, problems such as neurological diseases/trauma can cause this condition. I had a patient involved in a car accident that had sustained a head injury, and as a result, had developed hyperhidrosis. Also, traumas to the skin such as frostbite, can result in localized excessive sweating, too.

But unlike secondary hyperhidrosis, there are no underlying medical conditions.

Secondary hyperhidrosis refers to a generalized form of excessive sweating. Most women who have gone through menopause are personally acquainted with the hot flash, in essence a transient form of secondary hyperhidrosis. Other possible causes include:

• Hyperthyroidism
• Diabetes
• Neurological Disorders (including paralysis)
• Malignancy
• Tuberculosis (and other chronic infections)

THERAPY OPTIONS

How does one control excessive sweating? In secondary hyperhidrosis, the cause must be determined and addressed. But in primary hyperhidrosis, one can do any of the following:

• Block sweat from being released by the eccrine gland.
• Block acetylcholine from reaching it's intended target (the sweat gland)
• Reduce the amount of acetylcholine being released
• Remove the sweat glands

Antiperspirants

Antiperspirants are the first line of hyperhidrosis treatment. Now certainly you are thinking "But I have tried every antiperspirant on the market and nothing happened". True, your garden-variety daily deodorant may not have done the trick. Yet medical grade antiperspirants exist just for this reason.

All antiperspirants work by blocking the sweat ducts, preventing sweat from reaching the skin's surface. Aluminum (whether combined with chloride or zirconium) is soluble as long as the formulation is acidic. Once applied to the skin, contact with sweat raises the pH, causing the complex to precipitate out and plug the glandular opening.

First, if you've been using routine OTC antiperspirants containing aluminum chloride, you may first want to begin by trying a product utilizing aluminum zirconium tetrachlorohydrex glycine such as DERMAdoctor Total NonScents Ultra-Gentle Antiperspirant. This FDA approved antiperspirant active is less likely to irritate the skin and be more effective than common aluminum chloride-containing products.

Absorbent powders, such as Zeasorb Super Absorbent Powder, can be included to help reduce moisture, especially when skin folds are involved. Zeasorb is 3 times more absorbent than regular talcum powder. In addition to the original formula, it is also available with an antifungal agent - Zeasorb-AF Antifungal Powder, for those areas where excess sweating has led to yeast or fungal skin infections.

When it's time to turn to prescription options, dermatologists frequently prescribe Xerac AC or Drysol. Xerac AC contains 6% aluminum chloride while Drysol contains 20%. Either treatment is applied to the offending areas at bedtime, for approximately 3-4 nights until there is no longer excess perspiration. It is crucial that the areas be very dry before applying the product. The aluminum chloride needs to be reapplied as needed to control perspiration. Typically this is 1-2 times a week. Although these options can be helpful, they are not a permanent solution.

Oral Anticholinergic Medication

Certain prescription oral medications can prevent the release of acetylcholine, that neurotransmitter responsible for causing the eccrine sweat gland to go into overdrive. Pro-Banthine is frequently recommended and easy to take in a once a day (1.5 mg/kg every 24 hours) dose. Other anticholinergic medications include Ditropan and Robinul. The FDA has not specifically approved the use of these medications in the treatment of hyperhidrosis, so it's definitely an "off label" therapy.

The downside to this category of medicine; the potential side effects including dry mouth, blurred vision, constipation, urinary retention and palpitations.

Iontophoresis

Iontophoresis involves the plugging of the eccrine sweat gland by means of electrical current. Iontophoresis may be used to treat excessive sweating of the armpits, but it is more effective and tolerable (as well as practical) when targeted at problematic hands and feet. The site of choice is submerged in water and electricity is emitted by the device and gradually increased until the patient notices tingling. Three or four 10-20 minute sessions are performed weekly until improvement occurs. Maintenance is performed as necessary.

The Drionic device is probably the best known home unit in the U.S. although the Fischer Model MD-1a Iontophoresis unit has also received FDA approval.

Some amount of skill is needed to see good results. Possible side effects include irritation, dryness or blisters. Skip the concept if you're pregnant, wear a pacemaker or have metal implants.

Botox

The panacea of the new millennium, Botox has received FDA approval for the treatment of recalcitrant hyperhidrosis. For the same reason we understand how Botox works to eliminate wrinkles, Botox prevents the nerve from releasing acetylcholine resulting in sweat prevention.

Eccrine sweat glands aren't always clustered as one might expect, so prior to the injections, the dermatologist will map out your underarms with a simple process called Minor's starch test. First, make certain to shave prior to your appointment. After sitting quietly for 30 minutes, the skin will be wiped with an iodine swab and allowed to dry. Cornstarch will be lightly dusted across the area. Within a few minutes, the zones where the glands are producing sweat will turn a blue-black color. This is where the treatments will be given, making it unlikely that areas of glandular hyperactivity will be missed.

Each underarm will receive 50 units of Botox in a series of small injections (approximately 12-15 per side). Improvement of hyperhidrosis should be seen in just a few days. If excessive sweating persists for 2 weeks, it is prudent to repeat the Minor's test to determine if any areas were missed and do a Botox "touch up". Incredibly, Botox therapy for hyperhidrosis lasts 7 months on average although 28% of treated patients experienced sweat control for as long as 16 months.

Approximate cost for this procedure may run anywhere from $500.00 to $1200.00.

Botox injections can cause bruising, occasional bleeding, temporary muscle weakness (this is particularly true when injected around the thumb) and rarely allergic reactions. Avoid Botox if pregnant, nursing or if you have a history of neurological condition such as myasthenia gravis.

Endoscopic Thoracic Surgery

Finally, when all else fails, a more invasive procedure known as ETS (endoscopic thoracic surgery) may be considered to conquer primary hyperhidrosis. This is a more radical approach involving the cutting of the nerves (sympathectomy), which trigger the eccrine sweat glands. It is best used to treat hyperhidrosis of the palms.

Performed under anesthesia, a small cut is made and the patient's lung on the side of the operation is actually deflated. A small camera is used to visualize the proper nerves to be dissected. After this is accomplished the lung is reinflated and the incision is closed.

A good outcome is dependent upon the skill of the surgeon. Make sure if you are considering this operation that your physician is well versed and proficient at this procedure.

In addition to possible side effects commonly associated with any surgery, patients may experience compensatory hyperhidrosis (sweating elsewhere such as the back, stomach or lower extremities) or gustatory hyperhidrosis - excessive sweating triggered by eating.

MED e TATE

DERMAdoctor MED e TATE injection-free medicated hyperhidrosis control wipes contains a patent pending formulation of newest generation antiperspirant therapy with a blend of agents that mimic the effects of Botox when applied topically. With a technique so simple, it merely requires a single stroke of a towelette. Alleviates the need for cumbersome anti-sweating devices, ineffective topical prescriptions, drowsiness-inducing Rx meds and costly and painful Botox injections or invasive surgery.

Liposuction

Instead of cutting the nerves and preventing the stimulation of the eccrine sweat gland as occurs in ETS, liposuction removes the eccrine sweat glands themselves. Local axillary liposuction is performed as an outpatient surgery. It is not unheard of for some glands to be left behind, thus sweating is often reduced to a more normal level rather than completely eliminated in the treatment area.

Hyperhidrosis is more than ever a condition to which you should be able to say "no sweat". Ask your doctor about efffective options if you suspect you have hyperhidrosis.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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