What is hyperhidrosis?

Sweating is a natural and essential body function. Sweat is a watery fluid that is discharged from the sweat glands onto the skin surface. As the fluid evaporates, it plays a key role in cooling, thus helping the body maintain a stable core temperature. Hyperhidrosis describes excessive sweating, beyond what is needed for temperature control. In primary hyperhidrosis there are no underlying systemic diseases or other factors to explain the excessive sweating. Hyperhidrosis most commonly appears in three localized body regions: axillae (armpits), palms and soles. These areas are naturally rich in sweat glands and over-stimulated in patients with hyperhidrosis. The stimulation is driven by the autonomic nervous system and the neurotransmitter acetylcholine serves as the messenger between the nerve endings and the sweat glands.


Patients with hyperhidrosis often have suffered for many years and have a markedly impaired quality of life. They often have to change their clothes several times a day. Patches of moisture under the arms are both unattractive and unhygienic. Sweaty palms do not make a good impression when shaking hands. Moist feet may smell unpleasant, and frequently even the best shoes are damaged after a short period of time. In addition, moist clammy feet are predisposed to a variety of skin diseases, including fungal and bacterial infections as well as warts.



Who develops hyperhidrosis and when?

The disease usually starts in childhood, adolescence or young adult life under 25 years of age. The problem tends to run in families. The exact cause is unknown.



How can I recognize the disease?

The increased sweating appears unpredictably, independent of ambient temperature and is difficult to control. It is almost always symmetrical on one or most predilection sites: axillae, palms or soles. It interferes with daily life and appears more than once a week. Increased sweating does not occur during sleeping in primary hyperhidrosis.



Three grades of hyperhidrosis

Clinically primary hyperhidrosis is divided into three grades:


Grade 1:   Mild hyperhidrosis
Increased skin moisture (axillae, hands, feet)
Patches of sweat 10-15 cm in diameter (axillae)
Grade 2:   Moderate hyperhidrosis
Presence of drops of sweat (axillae, hands, feet)
Patches of sweat 10-20 cm in diameter (axillae)
Sweating limited to palms and soles (hands, feet)
Grade 3:   Marked hyperhidrosis
Sweat drips off of surfaces (axillae, palms, soles)
Patches of sweat ≥ 20 cm in diameter (axillae)
Sweating also involves sides and back of fingers and toes (hands, feet)



How is primary hyperhidrosis treated?

Both conservative and operative approaches are available. The therapy should be adjusted to the individual patient and the affected areas. A step-by-step to therapy is usually the best approach, something I discuss with each patient offering them many options. The recommendations are also contained in the guidelines which I participated in formulating: Definition and therapy of primary hyperhidrosis



Topical therapy with antiperspirants


The most effective topical antiperspirant is aluminum chloride hexahydrate. Aluminum salts reduce sweating by closing the sweat gland ducts without causing a back-up of perspiration. They are available as deodorant roll-ons or sticks, as well as creams for the hands and feet in concentrations of 10-30%. The medication is applied in the evening before going to bed, allowed to penetrate for 2-5 minutes, and then left on the skin. Therapy should be tried for several weeks before judging its effectiveness. The main side effect is skin irritation in the treated area.


Topical treatment with tannic acid products (cream, lotion or powder) also has an astringent, drying effect.




Tap water iontophoresis


Treatment with tap water in a waterbath with application of carefully regulated direct current from special devices is a useful therapy for hyperhidrosis of the hands and feet. With regular usage, initially daily for 15-20 minutes, sweating on the palms and soles is reduced. Later treatments can be reduced to 2-3 times weekly.




Treatment with botulinum


The most effective way to stop sweating is the injection of botulinum toxin directly into the skin of the affected regions. Botulinum toxin blocks the release of the messenger acetylcholine from the free nerve endings. Thus the signal for sweat production never reaches its target - and the sweat glands do not produce sweat! Botulinum toxin A is licensed for this purpose in the axillae. It is injected with a very fine needle in very small doses superficially into the skin. Multiple injections are required to insure that sweating is blocked over the entire region. Injecting the axillae is relatively painless and no anesthetic is required.


The „drying effect“ first appears within the first week and slowly increases to a maximal effect after 14 days. The effect is most dramatic following the first treatment; some patients even complain of a sticky feeling in their axillae. The fine normal layer of sweat that serves as lubricant is absent, but not really missed. This pleasant situation persists for around 4-7 months - much longer than the muscle-relaxing action used in treating wrinkles. When the moisture has once again reached an unpleasant level, the treatment can be repeated.


I only use the licensed products for increased sweating and for wrinkle treatment. Botulinum toxin A has been used medically for over 20 years; thus we have a good feeling for its precise use, action and side effect profile.




Operative therapy with sweat gland suction curettage


Suction curettage of the sweat glands is a very useful surgical procedure in the axillae. Its advantage over botulinum is that the results are permanent. A disadvantage is that the levels of sweat only are reduced by 60-70%. Later the operation can be repeated to once again reduce the sweating by another 60-70%.


The bundles of sweat glands that sit just underneath the skin are removed under local tumescent anesthesia using a vibration-assisted cannula to achieve a very superficial removal. An exact description of the technique can be found under the topic Body Contouring / Liposuction. After the suction has been performed, a curette is used to scrape the undersurface of the skin to remove as many of the remaining sweat glands as possible. The procedure lasts around 90 minutes, including time for the tumescent anesthesia to take effect. It can be performed on an outpatient basis.


A follow-up visit is required on the first day after the operation. The treated area will be slightly swollen as part of the healing process; there may also be a few tender areas throughout the axillae. Patients must avoid physical activity, especially using the arms, in the first 2-3 weeks after the operation to minimize the risk of complications. The timing of the operation should be coordinated with both professional and recreational plans; active sports should be avoided for 4 weeks. The short scars (5 mm long, 3 in each axilla) with normal healing are almost invisible. A definite reduction in sweat production and thus an improved quality of life are noticed almost immediately after the surgical procedure.


The Guideline - Definition and therapy of primary hyperhidrosis

of the German Society of Dermatology - AWMF-Guideline-registered: 013/059



In a personalized consultation, I will be happy to discuss with you which approaches are best for your hyperhidrosis.

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