Sweaty palms... treatment with surgery

If iontophoresis and botox are not treating the hyperhidrosis, the effected area of skin can be excised (usually only used for axillae), denervated with a sympathectomy, or liposuction can be performed to remove the sweat glands at the dermal/subcutaneous border (usually only used in axillae). The surgeries should only have to be done once, but are significantly more involved than the prior treatments discussed. The article in the Canadian literature referenced yesterday has a nice discussion about when to use which treatment. And Emedicine has a good summary of the surgical procedures.

Boni R. Tumescent suction curettage in the treatment of axillary hyperhidrosis: experience in 63 patients. Dermatology 2006; 213:215– 217.

Sweaty palms... treatment with botox

Botulinum toxin A blocks the release of the neurotransmitter acetylcholine at the neuromuscular junction. This toxin, which is produced by the Clostridium botulinum bacteria, inhibits the stimulation of muscular cells, including those surrounding eccrine sweat glands. Blocking the secretion of sweat glands in this way has proven to be an effective treatment usually lasting 3-4 months. It does, however, require multiple injections. With 1.5 cm standard spacing, my palms would need about 50 injections each.

Solish N, Bertucci V, Dansereau A, Hong HC, Lynde C, Lupin M, Smith KC, Storwick G; Canadian Hyperhidrosis Advisory Committee. A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007 Aug;33(8):908-23.

Sweaty palms... treatment with iontophoresis

Finding studies proving the efficacy of iontophoresis for hyperhidrosis was not as difficult as figuring out how iontophoresis works. The hands and feet are placed in a water bath and a direct electric current is run through it. This is a popular treatment if topical aluminum salts have failed. Iontophoresis is also used to help with the cutaneous absorption of drugs.

This article (and others following it) have related the accumulation of hydrogen ions in the sweat glands to secretory damage. With the electric current, water becomes acidified and the ions more easily penetrate the skin because of the current. They collect in the sweat glands and damage them. It takes multiple treatments for hyperhidrosis treatment, as after one treatment, there was only a mild decrease in activity with choline stimulation.

Sato K, Timm DE, Sato F, Templeton EA, Meletiou DS, Toyomoto T, Soos G, Sato SK. Generation and transit pathway of H+ is critical for inhibition of palmar sweating by iontophoresis in water. J Appl Physiol. 1993 Nov;75(5):2258-64.

Sweaty palms

Hyperhidrosis is excess sweating via the eccrine glands beyond what is required for thermal regulation. There are various guidelines for how much sweat produced over a certain body area is normal, but clinically no one uses these. The guidelines are used more for research than for actually diagnosing the condition. The loose definition for hyperhidrosis is excess sweating that interferes with daily activities.

Today I was just going to discuss different causes of excess sweating and the quality of life implications. Over the next couple days I'll discuss two of the treatments.

Emedicine has a great article if you are interested in details. I thought hyperhidrosis would have more information on the internet, but most of what I found were ads for various treatments.

Localized essential hyperhidrosis usually presents in childhood or adolescence as localized excess eccrine sweat production of the palms, soles, and/or axillae. The exact cause is unknown, but it is believed to be triggered by overactive sympathetic innervation causing excessive stimulation of the glands. Palms and soles sweating is not associated with heat, but more so with anxiety, so the excess sweating should stop when the patient is asleep or sedated. Generalized excess sweating may be caused by systemic disease and should be further investigated. The Emedicine article has a list of disorders under the "Causes" subheading that can present with localized or generalized excessive sweating.

I helped treat a patient with hyperhidrosis of the palms and soles, and it was interesting to hear her perspective on how this has affected her life. She doesn't like to shake hands and can't wear shoes without socks. The thing she was most looking forward to after her treatment was to wear dress shoes! Although her disorder is completely benign, the quality of life implications can be socially debilitating. A friend of mine has trouble with yoga because of her sweaty soles, and people with axillary hyperhidrosis suffer from embarrassing sweat stains. Depending on a person's age and occupation, the effects of hyperhidrosis can vary in severity.

First line treatment is topical aluminum salts (used in anti-perspirants), which are drying to the skin.

Aamir Haider and Nowell Solish. Focal hyperhidrosis: diagnosis and management.
Can. Med. Assoc. J. 2005 172: 9.