If only we don’t sweat the small stuff
Ling constantly sweats, even it’s over small stuff. She simply has no control over it. The sweaty palms and the constant perspiration of soles, resulting in the yucky wet feeling in her shoes were such turn offs that she became a social recluse, just keeping to herself and staying away from the social scene.
At 23, Ling feels that her world is crumbling around her. “Why? Why? Why?”… she asks herself. “Why did I have to develop such a condition? Why me? Why can’t I lead a normal life?. These have been the persistent questions tormenting her since her secondary school days when she started to be selfconscious of her condition.
Each time, it was an important occasion for her – like the girls’ night out with the boys, her first date, the first job interview – the sweating would get really excessive as if a sweat tap had been turned on at maximum for the gushing sweat flow.
Yes, she was constantly worrying about what other people would think of her and that prevented her from doing everyday tasks like shaking hands, holding hands, dancing… If it weren’t for her excessive sweating, she would probably be more outgoing but instead, she ended up being shy and withdrawn, simply afraid of what other people would think of her.
Although Ling does not suffer a major illness, excessive sweating or Hyperhidrosis is far from trivial. It is a common condition that affects 3% of the population. Excessive sweating can take a serious toll on a person. In addition to causing embarrassment and frustration, it takes a toll on one’s quality of life and ability to carry out simple chores. Handshakes become unpleasant, intimacy difficult and some types of work impossible. People with hyperhidrosis may have to change their blouses/shirts/ socks etc two to three times a day. Any part of the body may be affected but most commonly the underarms (axillae), palms, feet, face and groin are involved.
But, it’s not all gloom and doom. Hyperhydrosis can be treated.
Normal Sweating
First, let us understand sweating, which itself is both normal and necessary. It’s one of our body’s main ways of shedding the heat that is a byproduct of our metabolism .We all need to sweat to keep the body cool and regulate body temperature.
Our sweat glands are activated by nerves and these nerves respond to stimuli that include hormones, emotions and physical activity
There are between two and four million sweat glands distributed all over the human body. The two types of sweat glands are the “eccrine” and “apocrine” glands.
The eccrine sweat glands are responsible for hyperhidrosis. The main function of eccrine sweat glands is thermoregulation, a process that cools our body by evaporation of eccrine sweat. These glands are found all over the body with highest density on the palms, soles, axillae and scalp. The sweating mechanism is controlled by a segment of the nervous systems known as the sympathetic nervous system, which controls the body’s reaction to emergencies and other forms of stress. This sympathetic nervous system activates the eccrine glands through the chemical messenger acetylcholine. People with hyperhidrosis have eccrine sweat glands that overact to the acetylcholine stimulation and are generally overactive. More sweat than necessary is produced.
The role of the apocrine sweat glands is less well understood. They are thought to play a role in scent. The apocrine gland secretions are related to body odour and pheromones. The highest density of apocrine sweat glands are found in the axillae, breasts, ear canal, eyelids, nostrils, the external genitalia and the area around the anus.
Causes
Hyperhidrosis may be primary (meaning its cause is not another medical problem) or secondary (meaning it results from another existing medical problem or a side effect of medication).In primary hyperhidrosis, the excessive sweating is the medical problem.
Excessive sweating may occur in a focal (occurs only on certain areas of the body e.g. the palms, soles, and or generalized (large areas of body affected) pattern.
The two main types of Hyperhidrosis are Primary focal hyperhidrosis and Secondary generalized hyperhidrosis.
- Primary focal hyperhidrosis often begins in childhood and adolescence and most often affects the feet, hands, underarms, head and face. Both sides of the body are equally involved usually. Interestingly, people with this condition do not usually sweat when they are sleeping. It’s also been shown that this type of hyperhidrosis maybe be inherited with members of the same family suffering from this condition.
- Secondary generalized hyperhidrosis is excessive sweating that is caused by another medical condition or is a side effect of a medication. Unlike Primary focal hyperhidrosis, sweating involves large areas of the body, can start at any age and may occur during sleep. Conditions that may cause hyperhidrosis include infection, an overactive thyroid gland, menopause, obesity, diabetes, gout, heart failure and stroke. Some medications such as certain antidepressants and antihypertensives (blood pressure pills) can also cause this type of sweating.
Hyperhidrosis affects the quality of life of sufferers more than any other disease that dermatologists treat. It may cause discomfort and skin irritation, such as in the feet or skin folds. The sweaty areas are also prone to bacterial and fungal infections and infections which may lead to bromhidrosis (foul smelling sweat).
It is important to get a medical evaluation to ensure proper diagnosis is made and appropriate treatment is instituted. Treatment depends on the cause. The underlying cause in secondary hyperhidrosis must be addressed completely before other forms of treatment are considered.
Treatments
Antiperspirants
This is the first line of treatment as they are the least invasive, inexpensive and easy to use.The most common ingredientis aluminium chloride hexahydrate.
Once an antiperspirant is applied on the skin, the sweat dissolves the antiperspirant particles and pulls them into the sweat pores. Plugs are then formed just below the surface of the skin in the sweat duct. When the body senses that the sweat duct is plugged, a feedback mechanism then stops the flow of sweat. The plugs can stay in place for about 24 hours.
Iontophoresis
This is a treatment especially useful for hyperhidrosis of the palms and/or soles in people who have tried prescription or clinical strength antiperspirants but not improved. Iontophoresis entails using a medical device that sends low voltage current through water. The patient is required to immerse his hands or feet in a shallow pan filled with water and the low-voltage current is passed in this water. This process temporarily shuts off the sweat glands. It takes about 8-10 treatments done on alternate days to decrease sweat production. The treatments must be maintained for sustained results.
Botulinum Toxin Type A
Botulinum Toxin Type A may be injected into the palms, soles or underarms. This medication is a protein with the ability to temporarily block the secretion of the chemical that is responsible for “turning on” the body’s sweat glands. This chemical is known as acetylcholine. By blocking, or interrupting, this chemical messenger, botulin toxin “turns off” sweating at the area where it has been injected. This treatment is effective and may last for up to 8 months. Repeated injection is necessary to maintain the effect.
Oral Medication
The most commonly used medications for managing excessive sweating are medications that belong to the anticholinergic group. Anticholinergic medications such as oxybutynin, glycopyrrolate and propantheline work by blocking the transmission of the chemical messenger (acetylcholine) to the receptors on the sweat glands that are responsible for triggering sweating. Because similar receptors are located in multiple areas of the body, there can be a range of side effects from these medications such as: dry mouth, constipation, impaired taste, blurred vision, urinary retention, and heart palpitations. As all medications have possible side effects, the benefits must outweigh the potential risks.
Surgery
Mainly for underarm hyperhidrosis. The sweat glands may be removed by various methods like surgical excision (cutting), liposuction and curettage (scraping). All of the techniques mentioned above have the same goal: to remove or injure the sweat glands so that they can no longer produce perspiration. Sweat glands are located just beneath the skin (where the skin and the underlying fat meet) and are thus accessible for these types of interventions. For a number of reasons (including the dispersal of sweat glands and scarring) local surgeries are not done for palmar hyperhidrosis (excessive hand sweating) and plantar hyperhidrosis (excessive sweating of the feet). Other treatments such as iontophoresis and botulinum toxin are better choices for these areas.
Symphatectomy
This is a surgical procedure performed under general anesthesia. The nerve pathway associated with the overactive sweat glands is destroyed. It is mainly used to treat palmar hyperhidrosis. A common side effect of this procedure is “compensatory sweating” in a different part of the body. Compensatory sweating is excessive sweating that occurs on the back, chest, abdomen, legs, face and/ or buttocks as a result of this surgery. It may even be more extreme than the original sweating. Therefore, this procedure should be limited as an option in patients in whom all other treatments have failed.
Newer emerging therapies
The MiraDry device is a relatively new treatment that uses microwave energy to destroy the eccrine sweat glands in the axillae. Other emerging therapies that may prove beneficial in the future include laser, ultrasound and devices that utilize radiofrequency. More research and published data is needed on these modalities.
Hyperhidrosis is a physically, emotionally, physically and socially disabling condition that has a profound negative impact on sufferers’ quality of life. This problem is often underreported and hence undertreated. The diagnosis and treatment of patients with hyperhidrosis leads to a great improvement of patients’ quality of life and confidence. There is no need to suffer in silence anymore! It can be treated!
Dr. Priya Gill is a Consultant Dermatologist. This article is courtesy of Manipal Hospitals Klang. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.
Names mentioned in this article have been changed to protect the real identity of the patients.
The incidence of non communicable diseases in Malaysia is on an upward trend in recent times, as evidenced by the National Health and Morbidity Surveys conducted by the Institute of Public Health. One of the concerns among primary health care doctors is the prevalence of Diabetes Mellitus which stands at 15.2% of adults above the age of 18 years (NHMS 2011).
Though prevention is the main stay of management by primary health care doctors, they do however face the complications of diabetes in their day to day practice of medicine. One of the common complications is diabetic foot ulcer in various stages of neglect or mismanagement.
According to the National Orthopaedic Registry Malaysia (NORM) Diabetic Foot 2009 out of all diabetic foot ulcer cases that were admitted, as much as 33.8% underwent foot amputation.
The aim of primary health care doctors is to prevent all cases of diabetic foot ulcers from reaching a stage whereby admission is needed. This will then hopefully reduce the incidences whereby amputation is needed
There is high morbidity as well as mortality that is noted in cases of limb amputation among diabetic patients
In line with the Ministry of Health’s desire to increase the care of patients with non communicable diseases and it’s complications by the private sector primary health care doctors, the Society of Scientific Studies of the Manipal Alumni Association Malaysia is undertaking the task of creating an awareness on the need to manage diabetic foot ulcers effectively as an initial step. A series of CME/CPD activities is ongoing to ensure that doctors in the primary care setting are armed with the knowledge and expertise to manage the scourge of diabetic foot ulcers and it’s complications.
