| HYPERHIDROSIS A few of my patients suffer tremendously of whole skin constitutional hyperhidrosis beginning in early adolescence. There are no other systemic complaints and Thyroid function is normal. Does anyone have an idea for Rx? Did anyone try clonidine? or Biofeedback? Yoram Harth MD I have several patients with hyperhydrosis who responded well to Robinul (glycopyrolate). Start with 1 mg bid-tid, and titrate dose for an adequate response.Be sure to review the side effects of anti-cholinergics with your patient so they understand what symptoms to moniter for - some people seem to have difficulty relating the CNS effects with the medication. John Starr MD - An old, but often overlooked treatment for generalized hyperhidrosis (and even the palmoplantar or axillary types) is Robinul Forte (Glycopyrrolate 2mg) bid. Xerostomia is usually only moderate and the drug is well enough tolerated that I get many requests for refills. As with all non-standard drug uses, it pays to read the package insert, but in 18 years of use, I have had no problems. John Uhlemann MD I got a call today from a non-dermatologist physician here in Atlanta whose "daughter in Los Angeles has a terrible problem with excessive perspiration when she gets nervous or stressed." It seems she's in show business, so this is a problem cosmetically and the stress is unlikely to diminish...don't know if hot lights contribute or not. Dad says it's not limited to feet/hands or axillae "It's generalized." She's tried Robinul (don't know what dosage...what's optimal?) without much success, and is now on Clonidine (again, dosage?) "which has decreased it about 50%," according to Dr. Dad. He'd like some suggestions for therapy and/or an expert to refer her to (preferably in the So Calif area, I presume, but I'm sure they'll take anyone, anywhere.) My suggestion was to consider biofeedback/stress reduction psychological-type therapy to decrease the stimulus...other than that plus what she's already doing, I'm out of choices. Any thoughts from you clever folks on RxDerm-L? Marilynne Mckay MD - I've had poor luck with most medical approaches to include Drionic, aluminum chloride etc. But, I've had good luck with psychotropic agents. I've used benzodiazipenes (less now because of concerns about habituation), SSRI's lke Prozac and also Buspar. I've seen two patients who obtained excellent results with endoscopic transthoracic sympathectomy (see JAAD 33:78:95)...it seems safer and easier than the old open sympathectomies. Peter Lynch MD The first order of business is to define the etiology of the generalized hyperhidrosis. I assembled the following list for your perusal: acromegally (especially due to an intrasellar tumor in young people), thyrotoxicosis, ethanolism, chronic infection, collagen vascular disease, sarcoidosis, and finally pheochromocytoma. The latter is especially important to exclude in light of my therapeutice recommendation, phenoxybenzamine, 10 mg/day. This alpha adrenergic antagonist is useful in generalized hyperhidrosis. However, it may induce a hypertensive crisis if used in the setting of pheochromocytoma. Anticholinergic, muscarinic antagonists, propantheline bromide, 15 mg p.o. TID and methantheline bromide may also be useful, but their use is limited by side effects. I hope that this helps. Rhett Drugge, M.D. You need to add drug-induced hyperhidrosis to your differential diagnosis. This is listed as a side effect of a number of medications, including several very widely used antidepressants which Dr. Lynch suggests as therapy for hyperhidrosis. You didn't mention if your theatrical patient was on any medications. Mark Valentine MD - Beta blockers, in particular highly lipid soluble ones that cross the blood-brain barrier well [Inderal, Trasicor] are sometimes useful for stress-induced sweating. Kevin Smith MD FRCP - Among others that work for hyperhidrosis is ProBanthine (propantheline bromide). Jerry Litt The old anticholinergic Robinul in 1 or 2mg /day doses is relative effective without too many other anticholinergic side effects. L.J. Gregg,MD - bethanechol Guy Webster - Robinul 2mg daily, works fairly well for hyperhidrosis, with dry mouth only occasionally a problem. John Uhlemann - What is the etiology of the hyperhidrosis. If it is simply idiopathic and axillary, besides the anticholinergics, there have been reports anecdotal of Beta Blockers. The Beta Blockers may also work for the anxiety induced palmer types. Try a Beta Blocker with little lipid solubility so you wont get the CNS problems, like Corgaard. There was another anecdotal report of palmer sweating relieved by indomethacin tid! Diane Thaler - Just had a lady back yesterday doing fine and very happy ("Best Rx ever!") on Robinul (glycopyrrolate) 1 mg - 1-2 tabs po tid for excessive sweating of the hands, feet and axillae. Must try topical Robinul sometime to see if it works. Kevin C. Smith MD FRCPC I am sorry to be replying to your message so late. I am also sorry that I have no references to the use of Robinul; I wrote the directional down during a lecture at the American Academy of Dermatology at least 20 years ago. Generally, it is given as 2 mg b.i.d. ; some individuals do not tolerate this and do well on 1 mg bid. I hope this helps. John Uhlemann MD If your pt. has axillary hyperhidrosis, liposuction appears to provide significant benefit. Should probably be called "apocrinosuction" or "sweat gland scraping", though. Dan Mitchell, MD The unit is available from: General Medical Company Dept. Z-1 1935 Armacost Ave Los Angeles, CA 90025 I personally have not found it very helpful for my patients with hyperhidrosis The iontophoretic bath units seem more effective. Steve Wiener I've had a great string of success (eg. half a dozen happy patients in a row) using Robinul 1mg / ml in Drysol (or in water for those who complain that Drysol stings) applied daily, bid, QOD - whatever - to inhibit sweating. Don't know if other doses would work - I just picked 1 mg / ml because it's easy for the pharmacy to mix; and I stuck with it because the patients are happy. KC Smith MD FRCPC - There is a nice article in September's Cosmetic Dermatology, by Lewis Stolman, NYU. "Managing Patients with Hyperhidrosis". In addition to the ususal modalities, indomethacin, as a prostaglandin inhibitor, and diltiazem, for its effect on calcium flux and its role in generation of eccrine sweat are mentioned. Even though others on the list have had luck with anticholinergics, my patients don't. He lists two machines, Fischer Galvanic Unic, R.A. Fischer Co, Glendale, Cal Drionic, General Medical Company, L.A., Cal. I am sure telephone info has their numbers. Diane Thaler I have a patient with severe hyperhidrosis, unresponsive to Drysol, who does not want to take any oral medicines to control this condition. Will someone send me the phone number or address of the Drionic company, so he may try this device. Also what is your experience with your patient's results using this device. Jere J. Mammino, D.O. - Nice review of Rx options for hyperhidrosis in the current Cosmetic Dermatology. Mark Ling, M.D., Ph.D. I have a patient with palmar/plantar hyperhidrosis who wants to use the Drionic iontophoresis device in attempt to control the problem. She refuses to use Drysol/Robinul etc. I am not a fan of this device and I told her so but she wants to try it anyway. My problem is I no longer have literature on it and don't know where to tell her to get one. Anyone out there have an address I can give her. W H Burrow I dont know if this is the current address but it is current to 1990: General Medical Co 935 Armacost Ave, LA, Ca, 90025-5296. call: 1 800 HEAL DOC 1-800-432-5362 J Rivers 1. Drysol qhs or qohs 2. Robinul 1-2mg tid 3. "liposuction", although it is really "apocrine ablation". Using tumescent anesthesia, one inverts the liposuction canula, and scrapes the underside of the dermis. Sufficient sweat glands are destroyed to significantly reduce the hyperhidrosis. Dan Mitchell, MD Robinul (glycopyrrolate) 1-2 mg / ml in whatever (even in tapwater) is the most effective thing I've ever ordered. Shuts the sweat glands down nicely, no systemic problems. I have given Robinul tabs 1-2 mg po bid or tid, and this also works well and is well tolerated. Kevin C. Smith MD - Jack Resnick reviewed an article from Sweden on Maibach's tape review this month which may help. Endoscopic Transthoracic Sympathectomy, a closed procedure via a thorascope was performed on 850 patients for hyperhidrosis, axillary, facial , and hands. There was a 98% success rate, 17 patients had recurrance, all were redone, and 15 of these had cures. He called his favorite thoracic surgeon who performed the procedure as outpatient on 2 of his patients, both were successes. The surgeon actually was able to visualize the stoppage of sweating during the procedure. Diane Thaler I saw a patient recently who reported having received the "open" procedure for his hyperhidrosis with no improvement and worse with a troublesome Raynaud's afterwards.He is aware of the closed procedure,but declines. Pierre Jaffe Doesn't heat from the body and aluminum chlorhydrate generate HYDROCHLORIC ACID (thought if I put it in caps people would see it this time)-and that is why guys with white shirts have yellow armpit stained white shirts?" Diane Thaler Yes, aluminum chlorhydrate in the presence of sufficient moisture and heat will generate HCl. The small quantities of HCl formed following topical application of some antiperspirants has been associated with potential irritation of the armpit. The yellow staining of clothing is probably due to additional factors than HCl alone. Daniel Bucks, Ph.D. - The Hydroxyaluminium citrate (Alutrat) is an effective and safe astringent, without any of the inconveniences of chlorydrates and other inorganic salts of aluminium. On the basis of the foregoing studies there was the exigency to find a substance and a non-toxic formulation that was in accordance with the requested dermatologic and cosmetic needs. Aluminium salts come up to the expectations better. The most common inorganic salts, as chloride, hydroxychloride and sulphate were excluded because they are highly ionisable and consequently they form suddenly complexes with the epidermal proteins. So these salts are irritant for the skin and, above certain concentrations, they induce hydroxyadenitic inflammation. Besides, it has been shown some formulations precipitating proteins are not astringent. Other Authors demonstrated that the transmission electron microscopy of aluminium chloridrate (ACH)-treated sweat glands indicated that just as the duct leaves the epidermis, and passes through the stratum corneum to the skin surface, its lumen is completely filled with an electron-dense, amorphous material. This material, the counter part of the morin fluorescence with regard to relative location, is believed to be the plug, consisting of ACH or one of its reaction products, responsible for sweat gland inhibition. In contrast, untreated glands were patent and devoid of comparable material. Morin fluorescence microscopy of those glands revealed that aluminium was present within the duct, generally as a solid mass at the level of the stratum corneum. Occasionally, some aluminium fluorescence was also observed in the duct at the level of the upper epidermis. Fluorescence was never observed in control (untreated) glands. Last a fabrics corrosion has seen where they touched the formulation. In particular cellulose fabrics, like rayon and cotton, are exposed to this attack. This experience and others on antiperspirant formulations led to the synthesis of an experimentally highly competing and openly less toxic salt.It is an organic salt, less absorbed by the skin but with a high power in modifying sweat gland activity. It operates without the typical "impact" action of equiactive inorganic formulations. This organic salt is hydroxyaluminium citrate (Alutrat) that shows all advantages of aluminium derivatives, but does not produce any significant toxic effect, not even bland. It has no aggressive action and is used for antiperspirant formulations (sprays, podalic detergents, skin dusting powders) for face astringent lotions (tonics, masks, after-shave lotions), and for special hygiene detergents. According to experimental and clinic researches the conclusion was that hydroxyaluminium citrate shows a meaningful astringent action after sufficiently prolonged skin application, either from the physiological point of view, or for its capability of eliciting a dose-dependent effect. Giorgio Rialdi MD, Ph.D. | |
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