A New Dawn for Treatments in Hyperhidrosis

Hyperhidrosis affects 2% to 3% of the US population¹ and can significantly decrease a patient’s quality of life. The condition is characterized by excessive sweating all over the body or on specific areas, such as the axilla, hands, or feet, even during cool weather and sedentary moments. Those who have hyperhidrosis not only encounter physical discomfort but also the emotional distress that comes with managing the issue.

Given the associated stigma and burdens, experts and dermatologists alike have stressed the need for better treatments for the condition. In the past, treatments for hyperhidrosis have incrementally improved, but recent innovations from lasers to medically-treated wipes signify a new wave of progress in the cure for excessive sweating.

Starting With the Basics

Since hyperhidrosis can have many causes, it is important to first identify any underlying factors that may provoke secondary hyperhidrosis, such as medical conditions, infections, medications, and stimulants. Lifestyle changes, including increased stress and anxiety, can also trigger sweat glands to work harder. Knowing this information can help inform treatment options. 

If there are any underlying causes, it is best to try and treat or remove those factors before treating the hyperhidrosis itself. Otherwise, treatment generally begins with antiperspirant deodorants used under the arms or even on hands and feet. If over-the-counter varieties help the condition but do not seem to be strong enough, prescription-grade antiperspirants (eg, Drysol) carry higher amounts of aluminum chloride to further decrease the amount of sweating.

If prescription deodorants are still not strong enough or the patient’s symptoms occur all over the body, then it is time to consider other options. Thankfully, nonsurgical treatments for hyperhidrosis have evolved significantly over the past two decades and now cater to a wide variety of patient preferences and symptoms.² 

Advanced Hyperhidrosis Treatments 

While hyperhidrosis treatments have traditionally included antiperspirants, injections, and iontophoresis (and still do to this day), there are newer treatments that help provide additional relief from stubborn excessive sweating. 

OnabotulinumtoxinA injections. OnabotulinumtoxinA (OnA) injections (Botox) are used to control excessive sweating by paralyzing the muscles that stimulate overactive sweat glands. The treatment has been in use since 2004, and research has shown an 82% reduction in sweat production 16 weeks after one treatment³ and positive effects lasting up to 9 months post treatment.^4-6 The procedure only takes about 15 minutes to perform, and repeat injections are needed every 4 to 6 months. Though multiple injections may be uncomfortable for uneasy patients, these are usually well-tolerated and patients feel the therapy is worth their time. 

Microwave thermolysis. First introduced in 2011, microwave thermolysis (miraDry) is an innovative solution to counter hyperhidrosis. Completed in a dermatologist’s office in as little as an hour, microwave thermolysis targets axillary hyperhidrosis with a small, noninvasive device that sends thermal energy to eliminate overactive sweat glands.⁷ As a result, these glands do not grow back; instead, perspiration is more evenly distributed throughout the body. Only one or two procedures, spaced 1 to 3 months apart, are needed. Patients usually need 1 to 2 weeks to fully recover due to some swelling and discomfort from the procedure. 

According to research from the University of British Columbia,⁸ microwave thermolysis successfully reduced axillary hyperhidrosis by at least 50% in roughly 90% of patients who underwent the procedure. With an average sweat reduction rate of almost 82% at 12 months’ posttreatment, patients reported an overall satisfaction rate of 90% with this procedure.⁸ However, the device still needs to be optimized to target excessive sweating on other areas of the body. 

Iontophoresis. Iontophoresis has been used since the 1940s to help reduce palmar and planter hyperhidrosis,⁹ but recent improvements have made the procedure more effective for other areas of the body. The procedure involves submerging a patient in water and employing a device that sends painless, low-level electrical currents to target and temporarily block hyperactivity in the sweat glands. Some studies have shown its effectiveness,but iontophoresis is not an easy procedure and has varying degrees of success.^10,11

Oral medications. Depending on the patient’s symptoms and treatment preferences, oral anticholinergic medications can be prescribed to target generalized sweating and craniofacial perspiration. Examples include glycopyrronium (Robinul), oxybutynin (Oxytrol), benztropine (Cogentin), and propantheline, all of which help block the chemical receptors that cause an overabundance of sweat. These medications can be effective, but the effective dosage can cause side effects including dry mouth, constipation, blurred vision, urinary retention, and heart palpitations.

Glycopyrronium. As the latest advancement in hyperhidrosis treatment, glycopyrronium cloths (Qbrexza) were released in October 2018. These wipes make treatment simple and convenient for patients. The product’s active ingredient, glycopyrronium, blocks the receptors that cause excessive sweating. One wipe is used daily, and each wipe comes individually packaged for use under both underarms.

The International Hyperhidrosis Society¹² cites studies that show use of glycopyrronium wipes once daily for 4 weeks decreases sweating severity by 25% to 30% and reduces sweat volume by 50% in most patients. Studies also indicate that glycopyrronium is safe and well-tolerated on children as young as 9 years old.¹³ 

As an oral medication, glycopyrronium can cause side effects such as dry mouth, constipation, and blurred vision, among others as mentioned above. When applied topically, side effects of glycopyrronium may include the same systemic side effects as oral medication, though those are rare. However, topical application may cause other side effects, including redness, burning, or stinging.

Another disadvantage is that the effects of glycopyrronium treatment are not as long-lasting as those of OnA injections or microwave thermolysis treatments; instead, these wipes must be used daily to remain effective. Fortunately, insurance companies sometimes cover the product for patients, which can help to offset the high cost of the treatment. It should also be noted that some people report off-label improvement on other body parts that also experience excessive sweating.

Surgical options. Surgeries have always been viewed as a last-ditch effort to treat hyperhidrosis. As noninvasive treatment options have improved significantly, surgical options are needed less. 

Despite advances, if noninvasive treatments do not prove effective, liposuction can help by removing sweat glands to reduce symptoms of hyperhidrosis in targeted areas. One difficulty is that sweat glands are hard to see, even with the latest technology, so the effects of liposuction on hyperhidrosis can be highly variable. The good news, however, is that whenever sweat glands are removed, the results are typically permanent. 

The most invasive treatment option is endoscopic thoracic sympathectomy, a permanent nerve surgery that involves cutting the nerve signals that trigger hyperhidrotic sweat glands. A miniature camera is inserted underneath the hands or underarms while surgeons cut along the nerve paths associated with the overactive sweat glands. Doctors do not frequently recommend this surgery because it can cause serious negative side effects including irreversible compensatory sweating all over the body, hypertension, arrhythmia, and heat intolerance.

These procedures can be completed under local anesthesia in an office setting and recovery is just a few days. However, it does often leave patients sore for a week or two after, and limiting physical activity is recommended.

Speaking With Your Patients

Many patients who experience hyperhidrosis may face anxiety, emotional distress, or frustration with their condition. Research finds that patients with primary severe hyperhidrosis are more likely to suffer from anxiety and mild to moderate forms of depression.¹⁴ Unfortunately, the reverse is true too; anxiety and stress can, in turn, lead to higher levels of hyperhidrosis.

I have seen this vicious cycle firsthand. It is important to remind patients that while the condition is certainly frustrating, there are many treatment options available depending on their symptoms and preferences. For patients who have a long history of the condition, there is a comforting light (and dryness) at the end of the tunnel. n

Dr Choudhury is board-certified dermatologist and the chief medical officer at The Dermatology Specialists, a full-service dermatology practice with 11 locations across New York, NY. He is also a clinical instructor in the department of dermatology at the Mount Sinai School of Medicine in New York, NY. 

The author reports no relevant financial relationships.

References

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2. Vorkamp T, Foo JF, Khan S, Schmitto JD, Wilson P. Hyperhidrosis: evolving concepts and a comprehensive review.  Surgeon. 2010;8(5):287-292. doi:10.1016/j.surge.2010.06.002

3. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ. 2001;323(7313):596. doi:10.1136/bmj.323.7313.596

4. Glogau RG. Botulinum A neurotoxic for axillary hyperhidrosis. No sweat Botox. Dermatol Surg. 1998;24(8):817-819. doi:10.1111/j.1524-4725.19998.tb04257.x

5. Heckmann M, Ceballos-Baumann A, Plewig G; Hyperhidrosis Study Group. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. 2001;344(7):488-493. doi:10.1056/NEJM200102153440704

6. Vergilis-Kalner IJ. Same-patient prospective comparison of Botox versus Dysport for the treatment of primary axillary hyperhidrosis and review of literature. J Drugs Dermatol. 2011;10(9):1013-1015.

7. How It Works. miraDry. https://www.miradry.com/how-it-works/.

8. Hong HC, Lupin M, O’Shaughnessy KF. Clinical evaluation of a microwave device for treating axillary hyperhidrosis. Dermatol Surg. 2012;38(5):728-735. doi:10.1111/j.1524-4725.2012.02375.x

9. Pariser D, Ballard A. Iontophoresis for palmar and plantar hyperhidrosis. Dermatol Clin. 2014;32(4):491-484. Do:10.1016/j.det.2014.06.009

10. Dahl JC, Glent-Madsen L. Treatment of hyperhidrosis manuum by tap water iontophoresis. Acta Derm Venereol. 1989;69(4):346-348. 

11. Karakoç Y, Aydemir EH, Kalkan MR, Unal G. Safe control of palmoplantar hyperhidrosis with direct electrical current. Int J Dermatol. 2002;41(9):602-605. doi:10.1046/j.1365-4362.2002.01473.x

12. Topical treatments: anticholinergics. International Hyperhidrosis Society. https://www.sweathelp.org/sweatsolutions-newsletter/news-blog/413-finally-new-hyperhidrosis-treatment-fda-approved.html. 

13.  Bragança GMG, Lima SO, Pinto AF, Marques LM, de Melo EV, Reis FP. Evaluation of anxiety and depression prevalence in patients with primary severe hyperhidrosis. An Bras Dermatol. 2014;89(2):230-235. doi:10.1590/abd1806-4841.20142189