Sweaty hands and pits

I’ve recently had a query from a patient of mine that I ‘adopted’ from another colleague. They have hyperhidrosis, excessive sweating and periodically has Botox injections for relief. This is a really good and very safe treatment for what can be an incredibly embarrassing and almost socially debilitating problem. The alternatives are varied. Strong antiperspirants, obviously, something called Iontophoresis, and a surgical procedure called thorascopic sympathectomy.
Iontophoresis is essentially tap water electrolysis. There’s no consensus on how it actually works and despite the notion that electricity and water is generally regarded as dangerous in combination, in this situation it seems to have benefit for some. It involves putting your hands into shallow basins of water with a controlled current running. It has to be controlled to have a therapeutic, as opposed to fatal, effect so please do not connect your kitchen sink to the mains without first consulting your doctor.
Iontophoresis is probably an under-utilised method because of its dubious evidence (doctors love evidence to cite or refute in support or otherwise of a cause) but it is cheap and effective for some.
Thorascopic sympathectomy is the destruction of a set of nerves that form a chain inside the chest alongside the backbone. It is very effective too. It requires a general anaesthetic, the patients lungs to be deflated on either side and for a heat probe to be passed through a telescope to destroy the nerves where they communicate. The nerves, known as the sympathetic chain are a primitive bunch that involve themselves in auto regulation. That is to say reflex responses to changes in the environment. Sympathectomy is a more or less indiscriminate ablation of the sympathetic chain. You can’t predict where the actual nerves that control sweating in the hand or armpit are, so you burn a number of areas in succession, more or less hoping that there’ll be the desired effect on completion. There are adverse side effects. Pain after the procedure for a week or so, and a lung that usually needs re-inflating (not usually a problem provided it hasn’t been injured during the procedure). The most common and problematic side effect is ‘compensatory sweating’ in areas that haven’t been treated. So the torso, back and face can start to sweat more while the hands or armpits are dry. There can also be some effect on the appearance of the face with a drooping of the eyelid and dilatation of the pupil ; horners syndrome. Thorascopic Sympathectomy is better for hands than it is for armpits, but provides the most complete and long lasting treatment for hyperhidrosis.

Botox is an alternative that provides good relief for a limited period, typically 6 to 9 months. The toxin is injected in small amounts just deep to the skin throughout the affected area. This can be pretty painful as anyone might imagine. Anaesthetic creams are used to alleviate the pain but are of dubious efficacy. Personally, I’d use a regional anaesthetic block at the wrist to numb the area for a few hours before the injections. The Botox effect isn’t instant, the sweating reduces over a few days. The treatment is repeated when the effect begins to wear off. As more treatments are given, so the effect can reduce if the body establishes antibodies to the toxin molecule. It is an excellent treatment that has minimal down sides and certainly none of the risks of surgery. It just needs to be repeated and that might get expensive over a significant number of years.