Excessive Sweating – Hyperhidrosis & Bromhidrosis

What is Hyperhidrosis?

Hyperhidrosis—otherwise known as excess sweating—is often under­dia­gnosed and under­treated. Dr Prashant Murugkar focuses on the main diagnostic features and manage­ment of hyperhidrosis.

What is Bromhidrosis?

Bromhidrosis is a condi­tion often asso­ci­ated with Excessive Sweating, but some­times occur­ring on its own, that relates to Foul Body Odour that is caused by the decom­pos­i­tion of the sweat gland secre­tions by bacteria normally present on the skin.

Are there different types of Hyperhidrosis or excessive sweating?

Hyperhidrosis can be gener­al­ized by the area involved or clas­si­fied as primary or secondary based on the cause.

In primary hyper­hidrosis, the cause for the excessive sweating is not known; in secondary hyper­hidrosis, the primary disorder—such as pitu­itary or thyroid dysfunc­tion, diabetes mellitus or menopause—is respons­ible for the hyperhidrosis.

Primary axil­lary hyper­hidrosis is the most common loca­tion for excessive sweating in patients and often presents along with palmo-plantar hyperhidrosis.

What is the mechanism of Hyperhidrosis or Excessive Sweating?

Sweating is controlled by emotions through the limbic system and the thermo-regulatory center in the hypo­thal­amus. These affect the post-ganglionic sympath­etic outflow of the para-spinal sympath­etic chain. While the defin­itive cause of this condi­tion is yet to be elucid­ated, most evid­ence points to a hyper­active auto­nomic system.

How do I know that I have Axillary Hyperhidrosis?

The patient will often give a history of focal, visible, and excessive sweating that has come on without any apparent cause over the last six months. Often, he or she has a family history of similar problems.

To be diagnosed as primary axil­lary hyper­hidrosis, at least two of the following char­ac­ter­istics have to be present in an other­wise healthy patient:

• Bilateral and relat­ively symmetric involvement
• Impairment in daily activities
• Age of onset < 25>
• Cessation of focal sweating during sleep.

Are there grades of Axillary Hyperhidrosis or Excessive Sweating in the Armpit?

Assessment of sweat stains on shirts or blouses can give a clue as to the severity of the hyper­hidrosis. A mild sweat stain, 5–10cm, still confined to armpit; moderate, 10–20cm, still confined to armpit; severe, 20cm, reaching the waistline.

Minor (starch-iodine) test: this is a commonly used test, but it can be rather messy. A 2% iodine solu­tion or 10% povidone iodine anti­septic solu­tion is applied to both the armpits and allowed to dry; corn-starch powder is then brushed on to this area. The test is positive when the light-brown colour turns dark purple as an iodine-starch complex forms in the pres­ence of sweat. The area can then be photo­graphed as a preop­er­ative record of the affected area and also to gauge the response to treatment.

Despite nearly 1–2 % of the popu­la­tion being affected, there is extraordin­arily little aware­ness of this problem and the resources avail­able for its solution.

Can I get treatment for Hyperhidrosis, Bromhidrosis or Excessive Sweating on the NHS?

There are no nation­ally agreed guidelines for the manage­ment of hyper­hidrosis or Bromhidrosis in the NHS.

Are there any treatments for Hyperhidrosis, Bromhidrosis or Excessive Sweating?

There are several levels of treat­ments avail­able going from Over-the-Counter treat­ments avail­able at the phar­macy like Antiperspirants, Glycopyrrolate wipes, Water Electrophoresis, Botulinum Toxin Injections (Botox), Microwave reduc­tion of Sweat Glands using MiraDry, Surgical options like Curettage of sweat glands using liposuc­tion cannula and finally Sympathectomy.

What is QBREXZA?

QBREXZA® (glycopyrronium) cloth is a pre-moistened, medic­ated cloth towe­lette that comes in indi­vidu­ally wrapped packets. Apply QBREXZA once a day to reduce excessive underarm sweating.

Which Antiperspirants are best for Hyperhidrosis, Bromhidrosis or Excessive Sweating?

Antiperspirants can be roll-on gels or powders that bring about a reduc­tion of eccrine sweat produc­tion by phys­ical obstruc­tion of the ductal open­ings by the metal salts from the chem­icals used.

The most common ingredient is 20% aluminum chloride hexahy­drate, which is avail­able as Anhydrol Forte or Driclor. This should be applied every night after care­fully drying the skin for 5–7 days, or until the maximum benefit is achieved. Thereafter, the frequency of applic­a­tion can be reduced to once or twice a week.

It is important to wash off the medic­a­tion in the morning and some even suggest to neut­ralize the area with an applic­a­tion of baking soda. If the patient develops pain or has a rash, inter­rup­tion of treat­ment and applic­a­tion of a topical steroid such as 1 % hydro­cortisone cream can reduce the inflam­ma­tion. Once the this has settled, the anti­per­spirant, such as driclor can be restarted.

Can Botulinum toxin type A help with Hyperhidrosis, Excessive Sweating or Bromhidrosis?

Botulinum toxin type A—Botox, Bocouture, Azzalure or Dysport—is a puri­fied neur­o­toxin derived from clostridium botulinum. It works by blocking the release of acet­ylcholine at the neuro-muscular endplates of the sympath­etic cholin­ergic nerve fibers of the sweat glands.

After mapping the involved area by clin­ical obser­va­tion or the minor test, an outline is drawn out with a skin marking pen. The enclosed area is then divided into a grid pattern with each of the grid squares being approx­im­ately 1–2cm. This is because the disper­sion of the botulinum toxin when placed intradermally is about 1–2cm.

Under anti­septic precau­tions using a 30 gauge needle, 50 U (of a 100 U/4.0 mL dilu­tion) of Botox is injected intradermally (ensuring that a bleb is raised) into each axilla.

Most patients have a perceived benefit from the treat­ment within 1–2 weeks and have dura­tion of relief ranging from 6–18 months.

Is Botox or Botulinum Toxin Type A injections safe for Excessive Sweating or Axillary Hyperhidrosis, Hyperhidrosis or Bromhidrosis?

The main contrain­dic­a­tions for the use of Botulinum Toxin Type A, include an allergy to any ingredient of the formu­la­tion; patients with rare neur­o­lo­gical diseases such as myas­thenia gravis, Eaton Lambert syndrome; pres­ence of infec­tion at the site; lactating mother, or pregnancy.

Fewer than 1% of the patients exper­i­ence any kind of side-effects. The most common are compens­atory hyper­hidrosis (an increase in non-axillary sweating), injec­tion site pain, hot flushes, pruritus and rash.

What is Sympathectomy for Hyperhidrosis?

In sympath­ec­tomy, the fourth thoracic ganglion of the sympath­etic nervous system chain that controls the nerve supply to the sweat glands affected in axil­lary hyper­hidrosis is discon­nected using an open or endo­scopic approach to get relief from axil­lary hyper­hidrosis. However, it is asso­ci­ated with a high incid­ence of compens­atory hyper­hidrosis from other areas of the trunk and is more suited to treat palmar hyperhidrosis.

Are there any medicines I can take for Excessive Sweating or hyperhidrosis?

The use of anti­ch­olin­ergic drugs—propantheline bromide and glycopyrro­late work by blocking the acet­ylcholine secre­tion and can offer relief from the symp­toms. However, the incid­ence of adverse symp­toms, such as visual blur­ring, dryness across mucosal surfaces and constip­a­tion reduces their utility when given system­ic­ally. Glycopyrrolate has there­fore been delivered topic­ally using iontophoresis.

What is Iontophoresis for Excessive Sweating of the Palms or Palmar Hyperhidrosis?

Iontophoresis involves an applic­a­tion of a direct elec­trical current across the skin. The mech­anism of action of this modality is uncer­tain. While ionto­phoresis pads for axil­lary applic­a­tion are avail­able, the real utility of this modality is in treating palmar and plantar hyperhidrosis.

What other surgical treatments help with Axillary Hyperhidrosis or Excessive Armpit Sweating?

Surgery of the sweat glands is another treat­ment of this condi­tion and can include — retro­dermal curettage (essen­tially scrap­ping the sweat glands away) or liposuc­tion to remove the sweat glands from the under­sur­face of the axil­lary skin are also effective solutions.

What is MiraDry?

This is a treat­ment that uses Microwave radi­ation to reduce the activity of the Axillary or Armpit sweat glands. There seems to be a permanent reduc­tion of the sweat glands following one or two treat­ments, this is asso­ci­ated with dryness that can be permanent or long lasting/

What is the cost of Botox for Under Arm Sweating?

At Reforme Medical the following are the charges for Sweat Reduction Injections

Scalp Hyperhidrosis from £375 – 600 as per severity

• Axillary hyper­hidrosis from £400
• Groin hyper­hidrosis injec­tions £450
• Hands or Feet hyper­hidrosis £800 – 900