Hyperhidrosis Clinical Assessment

Patient history:

The patient will often give a history of focal, visible and excessive sweating that has come on without any apparent cause over the last 6 months. Often he/she has a family history of similar problems.

To be diagnosed as focal or primary axillary hyperhidrosis, at least 2 of the following characteristics have to be present in an otherwise healthy patient:

Bilateral and symmetrical involvement
Impairment in daily activities
Age of onset <25 yrs, and
Cessation of focal sweating during sleep

Assessment:

1. Ax of sweat stain:

Mild sweat stain 5-10cm still confined to armpit/li>
Moderate 10-20cm still confined to armpit/li>
Severe 20cm reaching the waistline/li>

2. Starch-Iodine test (Minor test):

2% iodine is applied to both armpits and allowed to dry; corn srarch powder is then brushed onto 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. This is a pre-op record of affected area.

Treatments:

1. Anti-perspirants containing 20% aluminium chloride hexahydrate, such as Anhydrol Forte or Driclor. They are roll-on gels or powder that bring about a reduction of eccrine sweat production by physical obstruction of the ductal openeings by the metal salts. They should be applied every nightafter carefully drying the skin for 5-7 days until max benefit is achieved and then frequency reduced to 1-2 per week. Wash off medication in the morning.

2. Botox - Botox type A is a purified neurotoxin derived from clostridium botilinum. It works by blocking the release of acetylcholine at the neuromuscular endplates of the sympathetic cholinergic nerve fibres of the sweat glands.

3. 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, it is mainly used for palmar and plantar hyperhidrosis.

4. Surgery of the sweat glands. This can include retrodermal curettage (scraping sweat glands away) or liposuction to remove the sweat glands from the undersurface of the axillary skin. However, these procedures carry a risk of infection and significant scarring.

5. 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 e.g. visual blurring, dryness across mucosal surfaces and constipation reduce their utility when given systemically. Glycopyrrolate hs been delivered topically using iontophoresis.

6. Sympathectomy – the fourth thoracic ganglion of the sympathetic chain controls axillary hyperhidrosis – the part of the nervous system used to control the sweat glands in the axilla. This can be managed 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 palmar hyperhidrosis.

Botox Procedure:

1. After mapping the involved area by the minor test, an outline is drawn out with a white pencil.
2. The enclosed area is then divided into a grid pattern with each of the grid squares being approximately 1-2cm. This is because of the dispersion of Botox being 1-2cm when placed intra-dermally.
3. Botox is diluted 100U/4.0ml dilution of saline. 50U each armpit.
4. Under anti-septic precautions, using a 30-gauge needle, 50U Botox is injected intradermally into each axilla (ensuring that a bleb is raised).
5. Ensure that injections are spread out evenly over the grids marked out, starting from the periphery and moving to the centre, ensuring even coverage of the injections.
6. Most patients have a perceived benefit within 1-2 weeks and have a duration of relief from 6-18 months.

Contra-indications:

Pregnancy/breast feeing

Allergy to any ingredient in formulation
Presence of rare neurological diseases such as Myasthenia gravis/Lambert eaton syndrome
Currently taking glycoside antibiotics

Side effects (fewer than 1% experience side effects):

Compensatory hyperhidrosis