Monday, April 20, 2009

Excess Sweating

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I have a nephew who has excess sweating of his feet which began as a child.   The problem has not gone away as he got older, nor has it spread to other parts of his body.  He has tried the new socks that say they will absorb sweat and keep the feet dry.  None of them work for him.  So this post is for him as I look for ways to help him.

Sweating is the release of a salty liquid from the body's sweat glands.  Sweating or perspiration is important in cooling the body.   It is common to sweat under the arms, on the feet, and on the palms of the hands.
When the production of sweat is in excess of the amount needed for cooling the body (thermal regulation) it is call hyperhidrosis (excess sweating). 
Hyperhidrosis may be primary or secondary.  Primary (essential)  hyperhidrosis is excess sweating in an otherwise healthy individual, like my nephew.
When excessive sweating affects the hands, feet, and armpits, it's called primary or focal hyperhidrosis. Primary hyperhidrosis affects 2 - 3% of the population.  Less than 40% of patients with this condition seek medical advice. In the majority of primary hyperhidrosis cases, no cause can be found.   It appears to run in families.
Secondary hyperhidrosis is associated with any number of systemic illnesses.  These including pheochromocytoma, thyrotoxicosis, diabetes mellitus, diabetes insipidus, hypopituitarism, anxiety, menopause, carcinoid syndrome, and drug withdrawal.  Nocturnal sweating, in particular, may be a clue to the diagnosis of tuberculosis, lymphoma, endocarditis, diabetes, or acromegaly.  Treatment of the underlying disease will decrease or cease the excess sweating in secondary hyperhidrosis.
Several common medications occasionally produce hyperhidrosis. These include tricyclic and serotonin reuptake inhibitors, opioid analgesics, acyclovir, and naproxen.

When looking for underlying health issues, it is important to know if there are any triggers (stress, anxiety, food, etc), if the sweating occurs mostly at night or during the day, which areas of the body are involved, is there an elevated body temperature, or any other problems. 
You should see your doctor, if:
  • You sweat a lot or if sweating lasts for a long time or can't be explained.
  • Sweating occurs with or is followed by chest pain or pressure.
  • Sweating is accompanied by weight loss or most often occurs during sleep and associated with a fever.
Treatments may include:
  • Antiperspirants. Excessive sweating may be controlled with strong anti-perspirants, which plug the sweat ducts. Products containing 10% to 15% aluminum chloride hexahydrate are the first line of treatment for underarm sweating. Antiperspirants can cause skin irritation.  The strong doses of aluminum chloride can damage clothing.
  • Medication. Anticholinergics drugs, such as glycopyrrolate (Robinul, Robinul-Forte) are rarely helpful.  Beta-blockers or benzodiazepines may help reduce stress-related sweating.
  • Iontophoresis. This FDA-approved procedure uses electricity to temporarily turn off the sweat gland. It is most effective for sweating of the hands and feet. The hands or feet are placed into water, and then a gentle current of electricity is passed through it. The electricity is gradually increased until the patient feels a light tingling sensation. The therapy lasts about 10-20 minutes and requires several sessions. Side effects include skin cracking and blisters, although rare.
  • Botox. Botulinum toxin type A (Botox) was approved by the FDA in 2004 for the treatment of severe underarm sweating, a condition called primary axillary hyperhidrosis. Small doses of purified botulinum toxin injected into the underarm temporarily block the nerves that stimulate sweating. Side effects include injection-site pain and flu-like symptoms. 
  • Endoscopic thoracic sympathectomy (ETS). In severe cases, a minimally-invasive surgical procedure called sympathectomy may be recommended. The procedure is usually performed on patients with excessively sweaty palms. It is not as effective on those with excessive armpit sweating. This surgery turns off the signal which tells the body to sweat excessively. ETS surgery is done while the patient is asleep under general anesthesia.  The surgery takes about a half hour. Patients usually go home the next day, but may experience pain for about a week.  ETS requires special training so make sure your doctor is properly trained. Risks include artery damage, nerve damage, and increased sweating. New sweating occurs in about 50% of patients.

Goldman L, Ausiello D. Cecil Textbook of Medicine, 22nd ed. Philadelphia, Pa: WB Saunders; 2004:2365, 2446-2447.
Hyperhidrosis; eMedicine, May 2, 2008; Robert A Schwartz, MD, MPH, Rachel Altman, MD,  George Kihiczak, MD


Just A Vet Student said...

All right, all-knowing guru, I have a question.

How come Botox treatments tend to last for months (Medline Plus says 3-4 months), whereas paralysis from the disease lasts about a week?

BTW, saw two cases of equine botulism this March. One presented very typically with weakness and hypothermia leading to the inability to stand. This yearling (about 600 lbs) spent a week recumbent on a "mat", more like a thick mattress. He got anti-toxin on the first day he came to the hospital, but it was too late, so we had to just ride it out. Every hour, he got a nice hard massage (coupage) and more baby powder applied, and every few hours, we put ropes around his legs and flipped him over. Yes, they do put horses on TPN! I haven't heard of an adult horse on a vent longer than for surgery, though, so it's good he kept breathing OK. The other horse presented originally as a colic (suspected abdominal pain), then started hanging her head and behaving very defensively, dangerously so. She threw one of our strongest (and biggest) people into the wall and banged up her arm pretty good! She became recumbent and cervical radiographs were performed; the rads didn't show anything, but we were unable to get good positioning due to her short, thick neck and recumbency. LS CSF tap unsuccessful; AO tap showed NSF. She was euthanized later that day -- she had started flopping around the stall out of fear and desperation. Rabies negative, which pretty much left botulism as the presumptive dx.

I also saw a case of fluphenazine toxicity -- tremors, partial seizure like episodes, oral stereotypies (EPS?). It was very sad, but he ended up recovering completely!

Thus ends my horse-related hijack of your blog. :)

rlbates said...

Horsetech, I always love it when you "hijack" with your stories.

Actually, the effects of botulism poisoning in humans can last for months.

Just A Vet Student said...

Interesting. Thanks! I wonder if horses just plain don't survive the worst cases of botulism. Perhaps there's an equine survivor bias in that they either get better within a couple weeks or are so bad off that they are euthanized very early on.

rlbates said...

Horsetech, the worse cases in humans end up on ventilators for several weeks until the diaphragm and intercostal muscles come back. Not sure that's possible in horses.

Just A Vet Student said...

No, that's not really possible in adult horses. It's possible in foals, but from what I understand it's not done in adult horses. I'm not sure exactly why or where the line is drawn. There are ventilators capable of treating adult horses that are used during anesthesia. Cost may well be a limiting factor -- the bill for the yearling who did NOT need to be ventilated or on oxygen was in the five figures, and that was for half of the fluids, parenteral nutrition, etc., that would be required for an adult horse.

I wonder if it's the problem of a full adult horse being not just mostly recumbent but completely motionless. The yearling that I saw this spring was able to paddle his legs somewhat and was half the size of many adult horses. While modern practices have reduced anesthetic complications, adult horses who are recumbent for a long period of time (measured in hours, not days) are prone to pressure myopathies and neuropathies which may prevent them from ever standing up again. They don't ventilate the down lung well, which is why we flip even neonates on a regular basis, and the problems associated with recumbency increase with size. The mostly recumbent adults (1200+ lbs) I've seen or had described to me either were able to get up for brief periods if prodded or were hoisted with a sling periodically.

I'll ask about this the next time I get to chat with one of the residents. There I go rambling again!

Thanks for letting me share my stories.

rlbates said...

The pleasure of your ramblings is all mine!

Anonymous said...

Why do you say that medications like glycopyrrolate don't work? The refernce material you use states the opposite...I am referring to the eMedicine posing from Dr Schwartz and Dr Altman which states they are 'effective'?

rlbates said...

Most sources don't, Anon. Feel free to try them and see if they work for you.

Anonymous said...

Thanks for your reply. I have tried them and used for the past 1 and a half years. Works well, for me no side effects unless I go high on my dose of the capsule. I use the glycopyssolate wipes a lot for my face, with no side effects, but the only reference I can find related to them is by a Dr Kim from Korea in the British Dermatology journal from 2008. Have you heard about them or know anything about them? Thx, Trey