dermatologic disorders
Hyperhidrosis
Treatment of Hyperhidrosis
Aluminum chloridehexahydrate solution Topicalglycopyrroniumtosylate Tap-water iontophoresis Oral anticholinergic drugs Oralclonidine Botulinum toxin type A Microwaved-based device Surgery Initial treatment of focal and generalized sweating is similar. Aluminum chloridehexahydrate(an antiperspirant) 6 to 20% solution in absolute ethyl alcohol is indicated for topical treatment of axillary, palmar, and plantar sweating; these preparations require a prescription. The solution precipitates salts, which block sweat ducts. It is most effective when applied nightly and should be washed off in the morning. Sometimes an anticholinergic drug is taken before applying to prevent sweat from washing thealuminum chlorideaway. Initially, several applications weekly are needed to achieve control, then a maintenance schedule of once or twice a week is followed. If treatment under occlusion is irritating, it should be tried without occlusion. This solution should not be applied to inflamed, broken, wet, or recently shaved skin. High-concentration, water-basedaluminum chloridesolutions may provide adequate relief in milder cases. (an anticholinergic drug) 2.4% cloth wipes can be used to treat primary axillary hyperhidrosis in people 9 years of age and older ( Treatment reference ). Caution should be used in patients who are sensitive to anticholinergic drug effects. Tap-water iontophoresis,in which salt ions are introduced into the skin using electric current, is an option for patients unresponsive to topical treatments. The affected areas (typically palms or soles) are placed in tap-water basins each containing an electrode across which a 15- to 25-mA current is applied for 10 to 20 minutes. This routine is done daily for 1 week and then repeated weekly or bimonthly. Iontophoresis may be made more effective by dissolving anticholinergic tablets (eg,glycopyrrolate) into the water of the iontophoresis basins. Although the treatments are usually effective, the technique is time-consuming and somewhat cumbersome, and some patients tire of the routine. can be used to decrease sweating but can be limited by anticholinergic adverse effects, including dry mouth, dry skin, flushing, blurred vision, Urinary Retention , mydriasis, and Oralclonidineis an alpha-2-adrenergic agonist that decreases sweating mediated by sympathetic nervous system activity. Botulinum toxin type Ais a neurotoxin that decreases the release of acetylcholine from sympathetic nerves serving eccrine glands. Injected directly into the axillae, palms, or forehead, botulinum toxin inhibits sweating for about 5 months depending on dose. Of note, botulinum toxin is approved by the U.S. Food and Drug Administration only for axillary hyperhidrosis and may not be covered by insurance for other sites of hyperhidrosis. Complications include local muscle weakness and headache. Injections are effective but painful and expensive, and treatment must be repeated 2 to 3 times per year. A microwave-based devicecan heat and subsequently permanently destroy sweat glands. Patients may benefit from two treatments at least 3 months apart. is indicated if more conservative treatments fail. Patients with axillary sweating can be treated with surgical excision of axillary sweat glands through open dissection or by liposuction (the latter appears to have lower morbidity). Patients with palmar sweating can be treated with endoscopic transthoracic sympathectomy. The potential morbidity of surgery must be considered, especially in sympathectomy. Potential complications include phantom sweating (a sensation of sweating in the absence of sweating), compensatory hyperhidrosis (increased sweating in untreated parts of the body), gustatory sweating, neuralgia, and Horner Syndrome . Compensatory hyperhidrosis is most common after endoscopic transthoracic sympathectomy, developing in up to 80% of patients, and can be disabling and far worse than the original problem. 