Hyperhidrosis

Excessive sweating, or Hyperhidrosis (Hyperhydrosis,) is a medical condition that can be devastating. Excessive sweating all day everyday can be awkward embarrasing and annoying.  Not to mention the health implications of sweating excessively. A person with excessive sweat will typically attempt to disguise the excessive sweating with clothing, powders, and pads - however this is often unsuccessful.

Iontophoresis-treatment is performed using hand- and foot-baths. The affected parts of the body are put in a treatment basin, filled with usual tap water. A weak DC electrical current is conducted through the baths by electrodes. This current is increased gradually to a certain intensity, so that the patient experiences a pleasant tingling sensation. The weak current inhibits the secretion of the sweat glands without damaging the glands themselves.  In the armpits the current is applicator via wet sponge electrodes. In the early stages of treatment, the affected parts of the body should be treated once a day for about 10-15 minutes. Generally 10 - 15 treatment sessions are sufficient to normalize the moisture content of the skin. After that the treatment frequency can usually be reduced to once or twice a week or less frequently when required.

Treatment

The initial treatment for hyperhidrosis is usually medical and does not involve surgery. There are ointments and salves available (i.e., Drysol) that are astringents that tend to dry up the sweat glands. Another treatment is iontophoresis. This consists of a treatment of electrical stimulation, usually in the hands. Patients place their hands in a bath through which an electrical current is passed. This treatment tends to "stun" the sweat glands and can decrease the secretion of sweat for periods of 6 hours to one week.

Effective treatment modalities vary from patient to patient requiring the physician to experiment with numerous options before finding the most efficacious choice. Suggested first line methods include 20% alminium chloride hexahydrate in anhydrous ethyl alcohol topically, and iontophoresis.

Therapy can be challenging both for patient and physician. Fortunately, numerous medical, surgical and electrical treatment options are now available. Treatment may require visualization of the affected area, which may be accomplished by the iodine starch test (spraying the area with a mixture of 0.5 to 1 gram of iodine crystals and 500 grams of soluble starch). The treatment options include topical and systemic medications, iontophoresis, injections of botulinum toxin, and sympathectomy:

Iontophoresis, introduced in 1952 (12), is one of the most effective, safe and inexpensive treatment options available (13-15).  It consists of passing a direct current (DC) across the skin. A representative study showed that in 25 patients with palmar hyperhidrosis, symptoms were abated after an average of 11 treatments (30 minutes per treatment at least four times per week) of either DC or AC/DC tap water iontophoresis. However, for undiscussed reasons, alternating current (AC) iontophoresis was found to be essentially ineffective after 25 treatments (16). 55 % of these 25 patients noted a family history of palmar hyperhidrosis (16). The side effects noted were burning and tingling of the treated area, irritation (erythema and vesicles), and the induction of possible burns at areas of minor skin injury (16). Numerous agents have been used in iontophoresis including tap water and anticholinergics. In order to induce hypohydrosis, treatment of each palm or sole for 30 minutes at 15 to 20 milli-amperes (mA) daily in tap water iontophoresis is required (17). Intact skin can endure 0.2mA/cm2 of galvanic current without negative consequences and up to 20 to 25 mA per palm may be tolerated (17).

The mechanism of action of iontophoresis is unknown. One speculation was that iontophoresis induced poral hyperkeratosis, thereby promoting poral plugging and inhibition of sweat secretion (18). However, no such poral plugging was found (19). Tap water iontophoresis is more effective than saline iontophoresis (20). Iontophoresis with anticholinergics is more effective than tap water iontophoresis, but may induce systemic side effects (21). Palmoplantar hyperhidrosis may be effectively treated with 10 to 12 treatments (30 minutes at 15-20 mA at least three times per week) and one to two maintenance doses per week of tap water iontophoresis, with the only complication being mild skin irritation (13). With the initial treatment, patients found worsening of their condition, but this resolved after three to five treatments (13). Complete abolition of sweating was found to last one to two weeks and sweating quickly returned without maintenance therapy (13). A newer study incorporated both, anticholinergics and aluminum chloride for one hour daily. It diminished the sweat secretion (via the anticholinergic) and caused blockage of the sweat gland (via the aluminum chloride) (22). This combination iontophoresis treatment compared to tap water iontophoresis resulted in a remission period of 20 days versus 3.5 days and a reduction in severity of symptoms of -3.1 versus -1.5  (22).

Biophysica Iontophoresis includes :          

·        A safety circuit which ensures constancy of current regardless of variations in electrical load conductivity of the water.

·        A reverser/alternator which reverses the electrical polarity every few minutes in order to treat both hands equally and to maintain acid/base balance (pH).

·        An indicator indicating the state of charge of the battery.  

·        A digital indicator indicating the applied current of treatment from 0 to 30 mA.

·        An indicator indicating that the battery power is switched on.      

References:

1.      Adar R, Kurchin A, Zweig A, Moses M. Palmar hyperhidrosis and its surgical treatment: a report of 100 cases. Ann Surg 1977; 186:34-41.

2.      Cloward RB. Treatment of hyperhidrosis palmaris (sweaty hands). A familial disease in Japanese. Hawaii Med J 1957; 16:381-9.

3.      Cloward RB. Hyperhidrosis. J Neurosurg 1969; 30:545-51.

4.      Tugnoli V, Eleopra R, DeGrandis D. Hyperhidrosis and sympathetic skin response in chronic alcoholic patients. Clinical Autonomic Research 1999; 9:17-22.

5.      Wenzel FG, Horn TD. Nonneoplastic disorders of the eccrine glands. J Am Acad Dermatol 1998; 38:1-17.

6.      Stolman LP. Treatment of hyperhidrosis. Dermatologic Clinics 1998; 16:863-7.

7.      Shelley WB, Laskas JJ, Satonove A. Effect of topical agents on plantar sweating. Arch Dermato and Syphilology 1954; 69:713-6.

8.      Sato K, Kang WH, Saga K, Sato KT. Biology of sweat glands and their disorders. II. Disorders of sweat gland function. J Am Acad Dermatol 1989; 20:713-26.

9.      Tkach JR. Indomethacine treatment of generalized hyperhidrosis. J Am Acad Dermatol 1982; 6:545.

10.   James WD, Schoomaker EB, Rodman MC. Emotional eccrine sweating. A heritable disorder. Arch Dermatol 1987;123:925-9.

11.   Sato K. The physiology, pharmacology and biochemistry of the eccrine sweat glands. Rev Physiol Biochem Pharmacol 1977; 79:51-131.

12.   Boumann HD, Grunewald-Lentzer EM. The treatment of hyperhidrosis of the hands and feet with a constant current. Am J Phy Med 1952; 31:158-69.

13.   Holze E, Alberti N. Long-term efficacy and side effects of tap water iontophoresis of palmoplantar hyperhidrosis: the usefulness of home therapy. Dermatologica 1987; 175: 126-35.

14.   Levit F. Simple device for the treatment of hyperhidrosis by iontophoresis. Arch Dermatol 1968; 98:505-7.

15.   Stolman LP. Treatment of excess sweating of the palms by iontophoresis. Arch Dermatol 1987; 123:893-6.

16.   Reinauer S, Neusser A, Schauf G, Holzle E. Iontophoresis with alternating current and direct current offset (AC/DC iontophoresis): a new approach for the treatment of hyperhidrosis. Br J Dermatol 1993; 129:166-9.

17.   Sato K, Ohysuyama M, Samman G. Eccrine sweat gland disorders. J Am Acad Dermatol 1991; 24:1010-4.

18.   Shelley WB, Horvath P, Weidman F, Pillsbury DM. Experimental miliaria in man. I. Production of sweat retention anhidrosis and vesicles by means of iontophoresis. J Invest Dermatol 1948; 11:275-91.

19.   Hill AC, Baker GF, Jansen GT. Mechanism of action of iontophoresis in the treatment of palmar hyperhydrosis. Cutis 1981; 28:69-72.

20.   Timm D, Meletiou DS, Sato K. Mechanism of galvanic current-induced inhibition of palmar sweating in hyperhidrotic patients. Clin Res 1987; 35:721A

21.   Abell E, Morgan K. The treatment of idiopathic hyperhidrosis by glycopyrronium bromide and tap water iontophoresis. Br J Dermatol 1974; 91:87-91.

22.   Shen JL, Lin GS, Li WM. A new strategy of iontophoresis for hyperhidrosis. J Am Acad Dermatol 1990; 22:239-41.

23.   Bushara KO, Park DM, Jones JC et al. Botulinum toxin - a possible new treatment for axillary hyperhidrosis. Clin Exp Dermatol 1996; 21:276-278

24.   Shelley WB, Talanin NY, Shelley ED. Botulinum toxin therapy for palmar hyperhidrosis. J Am Acad Dermatol 1998; 38:227-9.

25.   Schnider P, Binder M, Auff E, Kittler H, Berger T, Wolff K. Double-blind trial of botulinum A toxin for the treatment of focal hyperhidrosis of the palms. Br J Dermatol 1997; 136:548-52.

26.   Kotzareff A. Resection partielle de trone sympathetique cervical droit pour hyperhidrose unilaterale. Rev Med Suisse Romande 1920; 40:111-3.

27.   Hsia JY, Chen CY, Hsu CP, Shai SE, Yang SS. Outpatient thoracoscopic limited sympathectomy for hyperhidrosis palmaris. Ann Thorac Surg 1999; 67:258-9.

28.   Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol 1995; 33:78-81.

29.   Lai YT, Yang LH, Chio CC, Chen HH. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery 1997; 41:110-3.

30.   Heckman M. Complications in patients treated with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery 1998; 42:1402-4.