A registered nurse, aged around 20, is experiencing discomfort caused by profound hand sweating. Sh

Fråga: A registered nurse, aged around 20, is experiencing discomfort caused by profound hand sweating. She has tried several preparations available in herbal drug stores without success. Are there any medical treatments effective for this condition?

Sammanfattning: There are several treatment options for therapy of excessive palmar sweating. Topical aluminium chloride and iontophoresis seems to be preferable in mild to moderate cases and endoscopic transthoracic sympathectomy can be considered in severe cases not responding to other therapy.

Svar: Cholinergic neurones of the sympathetic autonomic nervous system innervate eccrine sweat glands. A subset of these sweat glands is located in the palms, soles and axillae and reacts to emotional stimuli.

Generalized hyperhidrosis affecting eccrine sweat glands located all over the body can be caused by autonomic diabetes neuropathy, hyperthyreosis, acromegaly, menopause and different malignant diseases. Hyperhidrosis of emotional origin in palms, soles and axillae may cause social embarrassment and occupational problems which is why several medical treatments have been used to try to treat this symptom.

Treatment with topical aluminium chloride hexahydrate is often the first treatment of choice in mild cases (1). Aluminium chloride in a 25 per cent solution in ethanol is available over-the-counter in Sweden. It is acidic and probably acts by diffusing into sweat ducts where, upon neutralisation, it forms gelatinous hydroxides which obstruct the flow of sweat. It also reversibly damages sweat duct epithelium and may cause inflammation (2).

In an uncontrolled study of 13 patients with palmar hyperhidrosis, Jensen and Karlsmark found that 12 out of 13 experienced control of sweating after 3-4 weeks of daily treatment (3). A similar result was reported by Goh (4). After four weeks of therapy, a significant reduction in sweating when comparing treated to untreated palms was found among twelve men. The main disadvantage of aluminium chloride therapy is its short duration of action; the patients in (4) reported that sweating returned to the untreated state within 48 hours of stopping the treatment.

Iontophoresis, ie the use of weak direct current through various parts of the body, is another treatment which has been used for many years but not documented until recently. The mechanism of action is proposed to be formation of plugs in the eccrine sweat glands but this has not yet been established (5).

In a randomised, double-blind controlled study in a group of 11 patients with palmar hyperhidrosis, tap water iontophoresis with direct current (median 4 mA) for 15 minutes was used. A good subjective effect was reported after a median of 10 treatments and sweat production was reduced significantly compared with the untreated hand. In six patients put on three months maintenance treatment (once every second week) sweating was found to be reduced by 81 per cent (6).

Systemic anticholinergics have also been used but the unpleasant side-effects are not well tolerated and long-term success is variable (7). Glutarhaldehyde and tannic acid (strong tea) are proposed to be effective in the treatment of palmar hyperhidrosis but undesirable side-effects have limited their use (7). In addition, there are some case reports concerning the use of indomethacin (8), iv clonidine (9) and phenoxybenzamine (7) in the treatment of hyperhidrosis.

For the most severe cases which do not respond to conventional medical therapy, surgical sympathectomy can be an alternative. An endoscopic technique has been developed quite recently. A thoracoscope is introduced in the upper anterior part of the thoracic cavity and the second, third and fourth ganglia of the upper sympathetic chain are diathermied or vaporised using a low power CO2 laser (10-12). In a study of 50 patients with palmar or axillary hyperhidrosis, 46 patients were satisfied with the results of their operation (mean follow up period 26 months). A common side-effect is excessive compensatory sweating over the trunk and upper thighs which 30 per cent of the patients described. Gustatory sweating was also reported by half of the patients (10).