Ask the Pharmacist

Q) I realize it’s normal to sweat more during your teenage years but this is getting ridiculous. I seem to sweat all day for no apparent reason. What can I do about this?

A) Excessive sweating is called hyperhidrosis and is a fairly common concern amongst Canadians (and other nationalities for that matter as well).

It is estimated that between 3 to 5% of us experience this and while it does not directly lead to severe health consequences (although in severe cases the skin in affected areas can become quite raw) it can be a significant source of embarrassment affecting confidence and emotional well being to the same extent as other skin disorders such as severe acne or psoriasis.

While hyperhidrosis can begin at birth, most cases of excessive sweating tend to start during a person’s teenage years as hormonal levels undergo dramatic changes. Sweating is usually a useful thing. It is one of the mechanisms by which our bodies are able to control its temperature. The liquid produced, literally cools our body down when our core temperature rises beyond a certain level.

Why some people sweat more than is necessary to maintain optimal temperature control is not entirely known but the condition is classified into two major categories based upon probable cause.

In primary hyperhidrosis, studies have shown that a number of genes seem to play a role meaning that it is an inherited, genetic predisposition. This theory is supported by the fact that a majority of patients with primary hyperhidrosis have a parent or sibling who have also dealt with this.

In secondary hyperhidrosis, the excessive sweating is caused by an often treatable underlying cause such as a medical condition (diabetes, gout, hyperthyroidism, Parkinson’s, shingles, obesity, pregnancy, some cancers and many others), substance abuse or from a medication you may be taking such as drugs that treat Alzheimer’s, propranolol (for high blood pressure), Effexor/ venlafaxine and fluoxetine/ Prozac (for depression), tamoxifen (a breast cancer medication) or the tricyclic antidepressants (such as amitriptyline which are frequently used for insomnia or nerve pain).

Hyperhidrosis can further be classified by whether it is focal or generalized. In focal, the more common subcategory, the excessive sweating is localized to one or more of the following areas: underarms, hands, feet and/ or face. Focal hyperhidrosis tends to be of primary origin (i.e. caused by genetics). With generalized hyperhidrosis, the cause is usually from one of the underlying factors listed above and the sweating generally occurs over the whole body.  Treatment for generalized secondary hyperhidrosis involves treating/ eliminating the causative factor rather than treating the sweating itself.

For primary hyperhidrosis, there are a number of treatment options available but the first step should involve using an antiperspirant that contains aluminum. Aluminum works by essentially plugging the ducts from which our sweat leaks out thereby essentially blocking the route by which sweat escapes onto our skin.

There is no proof that one is better than another but there are a few higher strength products (Xerac AC 6.25% & Drysol 20% to name just two) that theoretically should work better than the standard Right Guard type brands. The trade-off is that the higher the concentration of aluminum that is used, the more likely the patient is to get some degree of skin irritation from it.

This can be minimized by ensuring the product is applied only to dry skin (wet skin will increase the possibility of irritation, a cool setting on a hair dryer can be used to dry the skin if needed) and at bedtime (people sweat less at night making the aluminum more effective) allowing the aluminum the 6-8 hours it needs to plug the sweat glands. It can then be washed off in the morning (thereby minimizing skin irritation) and a deodorant can be applied thereafter.

If the effects do not last all day, some will benefit from applying the aluminum antiperspirant twice a day although using it more frequently does increase the chances of skin irritation. Once the sweating is under control, try reducing the frequency of application. Some get by with as little as 1 application every 3 weeks. For those who find the skin irritation intolerable but the aluminum effective nonetheless, a hydrocortisone 1% cream can be applied twice a day for up to two weeks to control the symptoms until hopefully your skin becomes more resistant.

Another possible solution is to try HydroSal which contains 15% aluminum along with 2% salicylic acid which is added to make the product less irritating and possibly more effective. The advantages of using an aluminum antiperspirant are many. They are usually well tolerated, easily purchased without the need for a prescription, relatively inexpensive and can be applied anywhere (although they generally do a better job in the underarms area then elsewhere). As well, there are no long-term concerns to the best of our knowledge for those who wonder if there is a link between aluminum application and either Alzheimer’s or breast cancer. 

The downsides are the skin irritation that some feel and the fact that this treatment takes 1 to 2 weeks for it to reach its full effectiveness. If none of these products prove suitable, a Botox injection can be considered. On the plus side, a single injection can last from 4 to 9 months, it isn’t a particularly risky procedure and its effectiveness and safety in treating hyperhidrosis of the armpits is excellent (94% report an improved quality of life). On the downside, Botox can be hundreds of dollars, the injections are painful (especially to the hands and feet) although a nerve block can help with that and decreased grip strength is possible if injected into the hands.

In iontophoresis, an ionized liquid (most often water) is passed through the skin by applying a direct electrical current. This purportedly plugs the release of sweat in a fashion similar to an antiperspirant. It can be done at home, needs to be repeated every 1-4 weeks and there is some evidence in can work well on hand/ palm hyperhidrosis. Downsides include the price, a delayed onset of action (effects are not seen until after 6-10 treatments) and the treatment itself can cause minor skin discomfort.

Other treatment options include a compounded glycopyrrolate which is applied to the affected area (our pharmacy manufactures this and it is recommended for hyperhidrosis of the face), the use of oral drugs known as the anticholinergics (such as oxybutynin which can be effective and inexpensive but too often cause assorted side effects such as dry mouth, drowsiness…) or surgery.