www.hyperhidrosisuk.org

Case Study #1 - A Patient's Journey

Julie Halford, specialist nurse, adviser 1,2, Laura Hunt, patient 3, George Millington, consultant dermatologist 4

1 The Hampshire Clinic, Old Basing RG24 7AL , 2 Hyperhidrosis Support Group UK, 3 London, 4 Norfolk and Norwich University Hospital, Norwich NR4 7UY

At age 5 this patient was offered limited and unpleasant treatments for her hyperhidrosis. Now an adult, she describes how iontophoresis has greatly reduced the symptoms of her conditions:

 

Hyperhidrosis and its management have been a huge part of my life since I was 5 years old. As I nervously awaited being reprimanded for doing something typically naughty, I noticed the sweat on my hands. More than being clammy, they ran with sweat, and as I cupped them the sweat rested in pools in my palms. I remember feeling embarrassed, frightened, and fascinated by the sight. Ever since, my life has consisted of finding increasingly cunning ways of trying to hide my embarrassing secret.

Getting through the childhood and teenage years

In a world where many debilitating and life threatening conditions exist, it may seem ridiculous to consider hyperhidrosis as a condition that can affect self esteem and an individual’s social development and identity. But it can and does, and it has certainly had a huge impact on my life. As a tactile, friendly, confident person, I had to change all my natural inclinations to disguise my hyperhidrosis for fear of discovery and the inevitable reactions of disgust and ridicule. Simple childish games and other day to day tasks required careful "coping" methods—for example, sports; turning brass door knobs (which were the only kind in my primary school); writing essays in summer; gesticulating when talking (which I do very naturally); wearing sandals; going barefoot; and shaking hands. In short, things that most people do without a thought all routinely caused me great anxiety, and I developed elaborate stories to excuse myself as there was often no way of participating and disguising my condition. If you have ever experienced revulsion as someone touches your hand or notices how damp they are, you can begin to understand how mortifying it can be when it occurs.

As a teenager, when we all want to fit in and we develop our sense of self, my body image and self esteem were damaged by my loathing of my condition and therefore of my own body. My love of dance had to be sidelined; I couldn’t take part in classes barefoot as I would slide all over the floor and leave puddles. I carried on with my singing and acting but cultivated ways to hide my hands when on stage and be apologetic to fellow actors I had to touch. Relationships were very difficult. I couldn’t hold hands, couldn’t be as tactile as I naturally am, and was frightened to become close to someone for fear they would find me revolting.

How iontophoresis has changed my life

My family has always been very supportive and reassuring; my father, having had the condition as a child, grew out of it in adulthood. They encouraged me to see our general practitioner, who was mildly sympathetic and prescribed Anhydrol Forte and other aluminium chloride products to apply topically overnight. These were helpful and did bring me some normality and relief, but they were very unpleasant to use and by no means wholly effective. When I moved to London at 22 to study at university, I thought I would make one final attempt to seek medical help and saw my new general practitioner. He was extremely helpful and suggested a referral to the Dowling Day Centre at Guy’s and St Thomas’s Hospital for iontophoresis.

The only previous option that I had found during my internet research was sympathectomy surgery, which seemed rather horrific. Iontophoresis entails the patient’s hands or feet being placed on a metal plate and gauze in two trays containing glycopyrronium bromide solution and water, or just water if preferred. The plates are connected to a machine generating varying degrees of electrical current, which is passed through the plates, effectively facilitating a circuit through the body (for example, left hand to right hand). This process is then repeated with the current flowing in the opposite direction.

Tap water does not work for me, so I need the glycopyrronium bromide solution; but I understand that tap water works for about 85% of people who use iontophoresis, and that this is the normal practice throughout the UK in many dermatology departments. If people do not get a complete cessation of sweating with tap water alone, then they are switched over to the solution.

The treatment feels different depending on the sensitivity of the individual. I am very sensitive to the electric current and the solution, and I experience most of the known side effects, such as extremely dry and sore mouth and throat and dizziness, usually up to 24 hours after treatment. I also use Vaseline on my wrists and cuticles to prevent burning. The sensation is like placing your hands on an electric fence. It is often uncomfortable and sometimes painful, although I am particularly sensitive. It is not known precisely how iontophoresis works, but it seems to be extremely effective in blocking the sweating temporarily.

Although the glycopyrronium bromide solution provides total relief in localised areas as well as the entire body, it also prevents serious physical activity for 24 hours after a treatment as it blocks the body’s ability to control temperature fully. Iontophoresis gives me relief from hyperhidrosis for about five days, with a steady decline in effects thereafter. I usually have my treatment once a week to maintain the effects.

Through the guidance, warmth, and support of the dermatology nurses, iontophoresis changed my life. It gave me, for the first time ever, total temporary relief from my hyperhidrosis. In short, I felt normal, as though a black cloud had been lifted. For the first time, I could wear sandals, enjoy a summer’s day, hold hands, touch someone on the arm, sit with my hands in my lap, enjoy formal occasions, and shake people’s hands without dread. These examples may all sound inconsequential, but they revolutionised my life.

Professionally, the improvement in my confidence for auditions and performances as a singer and actress has been immeasurable. It has been difficult, given my sensitivity and the side effects, to plan my time around my iontophoresis and arrange treatment times around concerts, rehearsals, and anything involving physical activity. However, the treatment has such positive benefits, both to my life and to my self esteem, that it makes any difficulties worth the inconvenience. Thanks to it and to the support of groups such as Hyperhidrosis UK, I can begin to see my hyperhidrosis as a condition I manage, not as a condition that manages me.



The clinician’s perspective

Hyperhidrosis is defined as sweating in excess of that required for normal temperature regulation. Primary or essential hyperhidrosis, which presents without an associated condition, is a common disorder. In developed societies, up to 1% of the population will be affected in a lifetime. The onset of symptoms, as in Laura’s case, is usually in childhood or adolescence. Rarely, persistent secondary hyperhidrosis is due to underlying endocrine, neurological, febrile, or genetic conditions. A secondary cause is more likely if the onset of hyperhidrosis occurs in adulthood. Although any body site may be affected, hyperhidrosis most commonly affects the axillae, palms, and soles of the feet.

Hyperhidrosis causes great emotional distress. Also, it often causes problems for the patient in the workplace if left suboptimally treated into adulthood. Laura’s story illustrates how it dictated her social activities from an early age.

Although I have never met Laura, her story provides a sadly illuminating account of the problems of delays in therapeutic interventions in this condition. I see many children and adolescents who have been referred to secondary care at an appropriately early stage. Unfortunately, many children and adults suffer in silence, with a condition that is easily perceived by some as a "non-disease."

Treatments are not always that effective either. Aluminium chloride is often ineffective for severe hyperhidrosis, but it should remain the first line treatment in the community. Iontophoresis is useful for treating the palms, soles, and axillae. The iontophoresis apparatus can be bought for home use, which may be convenient for some patients. It is ineffective for facial or truncal hyperhidrosis, both of which are common, especially after sympathectomy. Delayed compensatory hyperhidrosis is very common with this operation, and only an unpredictable minority of patients benefit, so I never recommend this procedure to anyone.

I use glycopyrronium bromide in generalised hyperhidrosis. It has quite a few potential side effects, but these are usually well tolerated in the age range that is being treated (older children and younger adults). Botulinum toxin is very effective in axillary hyperhidrosis, but it is rarely available on the NHS; the high cost of the product and the necessity to repeat applications approximately every three months limits its usefulness.

George Millington, Consultant Dermatologist

Treatments for hyperhidrosis:

Aluminium chloride antiperspirants (in the UK, Anhydrol Forte, Driclor, Odaban) are the first line of treatment but can cause irritation and do not work for many people
Iontophoresis (for hands, feet, and axillas) works for 85% of people using ordinary tap water. Failures using glycopyrronium bromide are rare
Botulinum toxin (for axillae) is available in a few private clinics for other areas of the body but is often not available in NHS hospitals. It costs £300-£500 per treatment and needs to be repeated every three months for maximum effect
Anticholinergics such as oxybutynin hydrochloride and glycopyrronium bromide (prescription only) work for many patients with generalised hyperhidrosis or those who experience compensatory sweating after endoscopic thoracic sympathectomy. However, they are not without side effects
Endoscopic thoracic sympathectomy is useful only when all other treatments fail and then should be considered only with caution as compensatory sweating is extremely common and often worse than the original problem
Retrodermal curettage (for use on the axillae only) is not available in many clinics, but in two thirds of patients the effects are long lasting
Disposable underarm pads are helpful to protect clothes
Glycopyrronium bromide wipes (available only online) are good for the face and hands in difficult situations

Resources
  • Globally, there are few reliable, non-commercial sources of information and support for people with hyperhidrosis. The following are among the best.

Hyperhidrosis Support Group—A British group led by a nurse specialist and run by volunteers; it provides information and support to people with hyperhidrosis and health professionals and seeks to raise awareness of hyperhidrosis and its treatments
International Hyperhidrosis Society—A non-profit organisation that provides information for patients (in English, French, Italian, and Spanish), promotes research, educates physicians, and raises awareness of how hyperhidrosis affects quality of life
DermNet NZ—A company run by the New Zealand Dermatology Society that provides high quality information for patients and clinicians on a wide range of dermatological conditions, including hyperhidrosis

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