Excessive sweating or hyperhidrosis - The Definitive Guide

Hyperhidrosis or excessive sweating is the production of sweat in quantities greater than physiologically needed to maintain thermoregulation. Affects between 1-5% of the population. and for many people it can become a condition that significantly affects quality of life. 

If you want you can listen to the Podcast I recently did for SBS or continue reading the article. You can also skip directly to the recommended treatments for hyperhidrosis.

Hyperhidrosis occurs when the body's sweat glands are overactive, leading to an increase in the number of sweat glands. excessive sweat production that is not justified by physical activity or an emotional response to stress. This condition is usually characterized by profuse sweating in the armpits, profusely wetting clothes, or excessive sweating on the palms of the hands and soles of the feet.

Causes of excessive sweating

Although the cause of hyperhidrosis is not known, it can occur in people who have abnormally large sweat glands or who are genetically predisposed to hyperhidrosis. Thus there are two forms of hyperhidrosis and two other variants that I will also discuss. 

Anatomical diagram of sweat glands

  Eccrine and apocrine sweat glands are responsible for excessive sweating. Source link

  • Primary or idiopathic hyperhidrosis: There is no known medical cause that can explain its occurrence. It is the most common and is caused by an overstimulation of the eccrine sweat gland.
  • Secondary hyperhidrosis: Excessive sweating may also be a sign of more significant medical conditions. It can be observed in patients with neurological, metabolic, neoplastic, infections or secondary to drugs. That is why it is important to visit a specialist for an accurate diagnosis.
  • Bromhidrosis or body odor: is a condition in which there is excessive body odor that is usually unpleasant. It mainly occurs in the armpits but can also appear in other body locations.
  • Chromhidrosis: It is a rare dermatological disorder in which a colored sweat is produced, especially in the armpits and face. Depending on the level of lipofuscin in the secretion of this sweat it can have different colors (yellow, green, blue or black).
 

Hyperhidrosis can also be classified as focal if it affects certain parts of the body with a higher concentration of sweat glands (armpits, hands, feet) or global if it occurs throughout the body.

How to avoid excessive sweating?

Now, having some basic notions about hyperhidrosis, it is important to establish the steps to follow in order to treat it effectively. When I see my patients in the office with this problem we establish different steps to follow:

  • Step 1: to make a proper diagnosis of excessive sweating
  • Step 2: assessing the impact on quality of life
  • Step 3: Complementary hygienic-dietary measures
  • Step 4: Choosing an effective treatment for excessive sweating
excessive sweating of the hands

Step 1: Make a proper diagnosis of excessive sweating

Before starting any treatment it will be necessary to make an accurate diagnosis and rule out causes of secondary hyperhidrosis. On many occasions a visit to the dermatologist will be sufficient to establish a diagnosis, while on other occasions we will need to request some complementary tests. During the visit we will inquire more about:

  • Physiological factors: such as age, sex and hormonal profile.
  • Emotional factors: relationship of sweating with stress, fear, anxiety.
  • Lifestyle: assess the impact of hyperhidrosis on quality of life.
  • Concomitant diseases: such as diabetes.
  • Environmental factors: relation to heat, humidity, etc.

Step 2: assess the impact on quality of life

Hyperhidrosis can have important consequences on people's quality of life and can also cause secondary dermatological complications such as skin maceration, bad odor (bromhidrosis), bacterial or fungal superinfections, chronic hand eczema, etc.

While excessive sweating can be quantified in many ways, what really matters is the impact it has on quality of life. For these, several severity scales have been studied to establish the importance of hyperhidrosis. For this purpose we use the following hyperhidrosis severity scale.

My sweating is not evident and does not interfere with my daily activities. Level 1
My sweating is tolerable but sometimes interferes with my daily activities. Level 2
My sweating is barely tolerable and often interferes with my daily activities. Level 3
My sweating is intolerable and always interferes with my daily activities. Level 4

Depending on the degree to which hyperhidrosis affects our daily activities, we will have to choose one treatment or another.

Step 3: Complementary hygienic-dietary measures

Before going into the specific treatment of excessive sweating, I would like to give you some tips proposed by our Spanish Academy of Dermatology and Venereology (AEDV) for patients with hyperhidrosis.

General hygienic measures

  • Use cotton clothingbreathable and avoid synthetic fabrics.
  • Wear cotton socks and leather shoes with good breathability, avoiding plastic or rubber footwear.
  • Shower once or twice a day with deodorant soap
  • Shave axillary hair
  • Avoid the intake of coffee, alcohol or hot spices that may increase sweating.

Dietary measures

  • For when the main problem is the odor of sweat (bromhidrosis).
  • Certain foods rich in sulfur can alter it, such as cabbage or broccoli.
  • Avoid alcohol as some of it may be excreted through sweat and cause odor.
  • It is not a matter of eliminating these foods from the diet, but to know which ones alter our sweat odor the most and to take them when we do not foresee an important social event.
Young woman showing significant sweating while dancing

Step 4: choosing an effective treatment for excessive sweating

In many cases hyperhidrosis is undiagnosed, misdiagnosed and untreated due to lack of awareness of the disease and available treatment options. In recent years, new and increasingly effective treatments have emerged that can help treat the different forms of hyperhidrosis.

Topical treatments for hyperhidrosis

It is usually the first line of treatment in patients with focal hyperhidrosis. For this purpose, there are deodorants and antiperspirants in order to reduce excessive sweating. The inhibition of excessive sweating in certain areas of the body is not counterproductive to health and can be performed at any time of the year.

1- Deodorants

Deodorants help control the bacterial growth that causes odor (bromhidrosis) but allow perspiration. Their mechanism of action occurs by masking odor through perfumes. Therefore They are NOT effective in hyperhidrosis.

2- Prescription antiperspirants

On the other hand, antiperspirants contain salts that act by dissolving in the sweat and temporarily block the duct of the sweat glands. (see figure) This achieves the transient sweat reduction between 20-40% and 20-40%. secondarily also improves odor by not allowing bacterial overgrowth. It is recommended to use them at night, when the glands are less active. It is also important not to use them on damaged or irritated skin.

Mechanisms of action of antiperspirants in hyperhidrosis

The best-known active ingredients of these antiperspirants are aluminum salts (aluminum chlorohydroxide, aluminum chloride or aluminum sequichlorohydrate). Some of them are over-the-counter and can be tried before consulting a dermatologist. 

Here are the ones I use the most in my practice, as first line treatment, in many of my patients with hyperhidrosis. 

driosec dermoprotector roll on anti perspiration

Driosec Roll on

Martiderm Laboratories
It is undoubtedly a very good option. In the case of mild sweating you can use the Driosec Dermoprotect Roll-On or, in more severe cases, the intensive version Driosec Intensive Roll-On.
Eucerin Intensive Antiperspirant Roll-on

Eucerin Antiperspirant Roll-On 48h

Beiersdorf Laboratories

Another good option for those with heavy sweating. Contains a high concentration of aluminum hydrochloride to prevent the accumulation of sweat and body odor.

hyposudol-roll-on

Hyposudol Roll-on

Viñas Laboratories

Finally, this roll-on formulated with 15% aluminum hydrochloride. It is indicated for the regulation of excess perspiration and to prevent odor. It does not contain alcohol and does not irritate.

3- Topical anticholinergic drugs

Sweating occurs when our body releases a substance called acetylcholine. Anticholinergics are drugs that act to reduce this excessive sweating. An example of an anticholinergic used for this purpose in Spain is Axhidrox®, which helps control the amount of sweating by blocking the action of acetylcholine in the sweat glands.

Botulinum toxin or Botox

The botulinum toxin was approved by the FDA for the treatment of hyperhidrosis in 2001. It can be used to safely control hyperhidrosis and is currently a very popular option due to its cost-effectiveness in the treatment of excessive sweating.

Botox helps control excessive sweating by temporarily blocking the chemical signals from the nerves that stimulate the sweat glands. There are numerous scientific studies that support the efficacy of this treatment, achieving a significant and noticeable reduction of sweating in up to 90% of cases. The average duration of the effects is 6-7 months at axillary level. In addition, it is a safe treatment and has virtually no adverse effects. Typical areas that can be treated with botox are the armpits, palms of the hands, soles of the feet and scalp or face.

Woman during botox or botulinum toxin underarm procedure

Application of botulinum toxin to the axillae in a patient with hyperhidrosis.

Surgery or sympathectomy

The upper thoracic sympathectomy or sympathicolysis is a surgical procedure in which a temporary or permanent peripheral disconnection of the thoracic sympathetic chain is performed. This treatment is the treatment of choice when other medical or topical treatments have failed and would be indicated in cases of palmar, axillary, facial hyperhidrosis and/or facial flushing. This treatment is performed in the operating room under general anesthesia and is considered very safe.

As results of the technique, very high efficacy data are described for the treatment of the territories previously described (>90%). However, one of the most frequent and worrying consequences is compensatory sweating of other territories, which can occur in up to 44% of patients.

Oral medications for excessive sweating

On some occasions, when sweating is multifocal and occurs in many body areas or is generalized, we can resort to oral treatments. These treatments are safe and have a satisfactory response in many cases. They are also inexpensive and easy to comply with and their advantage is that they do not produce compensatory hyperhidrosis as can happen with surgery.

Among the most commonly used and with the most scientific evidence are those of the family of anticholinergics such as oxybutynin and glycopyrrolate. They develop their effect by inhibiting sympathetic (nervous) activation in the sweat gland. As an adverse effect, oral dryness is very frequent and occurs in most patients, but it is very tolerable.

Treatments with specific devices

For some years now, some energy-emitting devices have gained increasing acceptance for the treatment of localized (primary focal) hyperhidrosis.

1- Iontopheresis

Iontopheresis is a non-invasive, well-tolerated and safe method for the treatment of localized hyperhidrosis, especially on the palms of the hands and soles of the feet. It is a very easy to use household device that simply requires tap water for its operation.

It is defined as an electrotherapy technique based on the application of direct current and low frequency (galvanic current). Initially, the treatment is carried out for 20-30 minutes every 1-3 days until the desired effect is achieved, and then reduced to once a week to maintain the result. It is up to the patient to find which treatment regimen works best to maintain the results.

Some studies suggest that up to 80-85% of patients with palmar hyperhidrosis notice a subjective improvement of their symptoms in 2-4 weeks. A tap water iontophoresis study showed an improvement of 33% on the soles and 37.5% in the axillae after 14 days, which increased to 78% and 75% respectively in 20 days.

2- Miradry®.

It is a device that uses microwaves to selectively heat the skin to atrophy the sweat glands in the underarm area. It is used only for the treatment of hyperhidrosis and axillary bromhidrosis. Different clinical studies show that in the armpits up to 80% of cases permanently. Although it is a safe treatment, complications have been described, so it should always be performed in the hands of experts.

3- Bipolar radiofrequency

It is one of the latest treatments being introduced for the treatment of axillary hyperhidrosis. Fractional radiofrequency devices with microneedles allow the delivery of energy into the deep dermis without destroying the most superficial layer of the skin (epidermis). Studies have shown that a decrease in the size and number of sweat glands is achieved but not their destruction.

In a recent comparative study vs. botulinum toxin the efficacy of both treatments was studied. It was observed that Botox was more effective than bipolar radiofrequency.

Conclusion of excessive sweating

Although not life threatening, hyperhidrosis can be embarrassing, affecting daily life both socially and professionally. But the good news is that it is treatable. Understanding the treatment options is critical to then establish with your dermatologist an optimal treatment depending on the characteristics and location of the excessive sweating.

Hyperhidrosis and bad odor in the armpits of a young man after a stressful meeting

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Sebastian Podlipnik - Skin cancer

Sebastian Podlipnik

Dermatology Blog

I am a dermatologist and cum laude MD and author of multiple research studies. I specialize in skin cancer, laser technologies and cosmetic dermatology. The intention of this blog is to bring you closer to topics of interest in dermatology and research.

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