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The problem of excessive sweating and how to solve it

Excessive sweating is a modern problem. Sweating normally occurs when one’s body temperature is high and acts as a temperature-lowering physiological mechanism.

However, it has been theorised that sweat on the hands may have had a function in our past to help us increase the strength of grasping when man still lived in trees.   

Strangely enough, the problem of excessive sweating may be more evident in winter when soaking and dripping hands may draw unwanted attention, whereas in summer such wet hands can be passed off as a consequence of our hot weather.

Excessive sweating is a modern problem

Excessive sweating is called primary hyperhidrosis in medical parlance and is defined as excessive sweating in certain body areas without physiological reasons. People who suffer from hyperhidrosis experience social and emotional deterioration in their quality of life. Excessive sweating usually starts in teenage years, and its cause is not well understood.

It is thought to be due to an overactive sympathetic nervous system, the one that triggers the fear, flight or fight reaction. An attack episode of excessive sweating in a person with hyperhidrosis leads to anxiety, which in turn further precipitates further sweating, usually in the hands and feet on both sides in a mirror image.

This condition must not be mixed up with other medical conditions that lead to generalised sweating all over the body or secondary hyperhidrosis such as obesity, menopause, infections, fever, thyroid disease and diabetes when blood sugar levels have become low (such as following too much insulin).

Other conditions include Complex regional pain syndrome (CRPS), where severe pain affects a limb; it can spread to other limbs or even the whole body and is often caused by an initial injury or accident that is often relatively minor; best treatment involves a pain management specialist.

Drugs including anti-depressants (both selective serotonin re-uptake inhibitors (SSRIs)and tricyclic anti-depressants), opiates and non-steroidal anti-inflammatory drugs (NSAIDs) may also cause generalised sweating.

Hyperhidrosis affects routine activities in one’s life and may even affect certain careers. For example, I can relate stories of embarrassed bank clerks who are afraid of shaking their clients’ hands at the end of a meeting because their hands are dripping wet; just drying their hands by rubbing them on their trousers/skirt may not be sufficient. Or a machinist in a metal machining workshop from whose hands items would slip, fall and be ruined. Other unsocial experiences suffered include wet shirts or blouses, sweat stains under armpits and bad odours.

There is often a psychological overlay to these stories, with the excessive sweating the root cause leading to devastating emotional effects, including elevated social stress levels and depressive symptoms.

Such a person may develop a stress response from sweating that leads to a vicious circle with further stress and even more sweating. It may lead to behavioural changes, such as avoiding handshakes and sandals or flip-flops, wearing dark clothes and changing several times during a day, worry about showing stained armpits, lack of self-confidence, shame, fear of consequences and disturbed interpersonal relationships, e.g. not being able to attract a boyfriend or girlfriend.

The condition affects two to three per cent of Western populations, occurring equally commonly in men and women. In Malta the problem may be exacerbated by our hot humid weather. Extrapolating the above data to a population of 450,000, one can expect to see over 13,000 with this problem.

What treatments are available?

▪ Isopropyl alcohol applied topically can reduce sweating for a short time, up to two hours, and more importantly it kills off the bacteria that produce the bad smell.

Botox injection into the palms works well but is expensive and does not last for a long time.Botox injection into the palms works well but is expensive and does not last for a long time.

▪ Deodorants with aluminium salts. These deodorants work especially in the armpits and in gel/sustained release form can approach 24-hour coverage. They are not that useful for the palms.

▪ Tablets. Anticholinergic medication can be prescribed but their use is limited by their side-effects, including dry mouth, constipation, urinary retention, loss of visual ability to focus and dilatation of the pupils.

▪ Electrophoresis or iontophoresis is a process where the hands are placed in tap water and an electric current is applied to drive ions across the skin. This is thought to affect the neuronal endings. Responses to this treatment vary considerably.

▪ Botox (botulinum toxin type A) injection into the palms works well but is expensive and does not last for a long time. It is recommended that the palms be injected every year just before the summer starts to provide cover for approximately two months. Unless patients pay for repeated expensive injections, this treatment does not provide year-long protection.

▪ Video assisted thoracic surgery (VATS) sympathectomy. VATS sympathectomy involves using keyhole surgery to disrupt the sympathetic supply that drives palmar hyperhidrosis by dividing the sympathetic trunk or chain. Access is through two five-millimetre incisions and one 11mm incision for the thoracoscope (camera). Patients are discharged home the same or the next day, depending on the operation start time.

Since the incisions are very small because of the keyhole approach, patients report only minor discomfort for a few days after the operation. About 95-98 per cent of patients will be cured of excessive palmar sweating. Compensatory sweating in other parts of the body occurs as a side-effect from the procedure, but this is usually mild and rarely problematic. Division of the sympathetic chain below the level of the second rib for the treatment of hyperhidrosis means that the risk of Horner’s syndrome (decreased pupil size and drooping eyelid) can be completely avoided. The advantage of this procedure is that the treatment is permanent with hyperhidrosis returning very rarely due to regrowth of nerves.

▪ The treatment of VATS sympathectomy for palmar hyperhidrosis is now available in Mater Dei Hospital. Sufferers of excessive palmar sweating who have tried conventional remedies and found them lacking can call Mater Dei Hospital on 2545 5486 for more information.

Aaron Casha is a consultant in cardiothoracic surgery with a special interest in VATS sympathectomy and thoracic surgery. He is also a senior lecturer at the University of Malta.

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