Health

For sufferers of hyperhidrosis, excessive sweating often leads to feelings of shame, loneliness and depression. Just knowing it is a recognised condition can be the first step to regaining confidence and control. By Michele Tydd.

Hyperhidrosis and sweating a solution

Botulinum toxin A (known by the trade name Boxox) is used to treat hyperhidrosis.
Credit: MENDIL SA / Alamy

As a Sydney lawyer just starting out, Eliza Campbell soon learnt a few tricks to hide a disorder that had troubled her since high school. The most confronting situation was greeting clients and other lawyers with a handshake because of her constantly sweaty palms.

“They weren’t dripping but I could see there was enough sweat to make people wipe their hands on their suits after they’d shaken my hand,” she recalls.

“I found ways to avoid the situation by carrying folders in both hands when possible and also by wearing clothes with pockets so I could stick my hands in and dry them on the fabric just before contact.”

Campbell is one of about 2 per cent of Australians who struggle with spontaneous excessive sweating on different parts of the body, a disorder she developed when she was about 14.

Known as hyperhidrosis, it is physically harmless but its psychological impact is well documented and can lead to loss of confidence, as well as isolation and depression.

While perspiration is necessary for the body’s temperature control, hyperhidrosis, which is caused by overactive eccrine glands, has no physiological benefit, says Sydney dermatologist and researcher Dr Robert Rosen.

“The eccrine glands become very active around puberty and a lot of people at that age think it is a hygiene problem rather than a treatable medical disorder, and that in itself is an issue,” he adds.

“It’s quite cruel really because it hits people who are vulnerable the hardest – those who are trying to get through school, trying to get jobs or to establish relationships, and then they have this to deal with as well.”

Axillary (underarm) hyperhidrosis is most common, followed by the feet, palms and craniofacial area (head and face). People can suffer with one or multiple sites and intensity can range from glistening surface residue to dripping sweat that saturates clothing and creates an odour, making it difficult to work and socialise.

A common theme among a global hyperhidrosis support group, which has more than 6000 members, was they often went for years thinking they were the only sufferers because the condition is not commonly spoken about.

Many express feelings of shame, loneliness and depression and are often desperate to find the right treatment or one without debilitating side effects. One young man described it as a “life killing” disorder, and many speak about the great lengths they go to hide it in public.

The first reported treatment involving targeted medication for hyperhidrosis was reported in 1950. Before that, surgery to cut or block the sympathetic nerve that triggers the need to sweat was developed in the late 19th century but it was fraught with complications, according to a 2014 historical review of hyperhidrosis treatments in the Journal of the Royal Society of Medicine.

Treatments now include specific deodorants, topical creams, oral medication and the more recent botulinum toxin A (commonly known by the trade name Botox) injections. Surgery is usually the last resort.

Botox was first used to treat hyperhidrosis in the mid-1990s. Dr Rosen co-wrote Australia’s first long-term assessment on its efficacy in a 2017 peer-reviewed paper published in the Royal Australasian College of Physicians Internal Medicine Journal.

Axillary hyperhidrosis was the review’s focus as it is the most common type, and as such its treatment was approved for a Medicare subsidy in 2013.

Rosen’s review found Botox to have a high level of patient satisfaction, which was based on data from more than 200 patients over 10 years and an internationally approved assessment tool.

“When I started training about 25 years ago, it struck me that the existing treatments for hyperhidrosis were not terribly good and I knew there had to be something better,” says Rosen.

“I took part in a bunch of trials, lectures and workshops on botulinum toxin A, and helped train other dermatologists in the treatment technique that led to regulatory approval.”

The therapeutic target is the neural synapse where botulinum toxin inhibits release of acetylcholine, which, among other functions, increases bodily secretions.

The focus of his latest review, which is yet to be published, looks at palmar hyperhidrosis, where sufferers sweat profusely from their hands.

It assessed a cohort of 30 patients – 15 males and 15 females aged between 16 and 47 – who received Botox injections over a four-year period from 2015 to 2019.

Based on data analysis and phone interviews, Rosen’s study found that 28 of the 30 patients experienced a reduction in sweating during the period.

“We also confirmed a hereditary trait, in that about 40 per cent of participants in this and the previous review had a first-degree relative with the disorder,” he says.

“There was only one case of compensatory sweating [when the sweating in one location stops but moves to another location]. Seven patients reported a mild transient decrease in grip strength which lasted a median of two weeks. Only one patient complained of transient numbness, possibly due to topical local anaesthetic use.

“You have millions of sweat glands all over the body so if you stop it at any of the hyperhidrosis sites, your body can still sweat normally in the other parts of the body for thermostability.”

The cost of Botox injections varies from clinic to clinic and depending on how much is needed for each patient, but it can range from a few hundred dollars to $1000 a session. The Medicare rebate (for underarm treatment only) is about $215 but is limited to three sessions per year.

Eliza Campbell, now 36, battled on for nearly a decade before learning her sweating was a recognised condition.

She says its impact became more psychologically complicated in adulthood. Where she initially felt shame at school among her friends over being different, the sweating later became a professional hindrance and risked affecting her career trajectory.

“People tend to associate sweating with awkwardness or being nervous and not a confident person,” she says. “I didn’t want that because that perception might undermine my competency.

“I never tried to explain to anybody, I simply avoided the situations. So finding out it was a disorder was a huge relief because I could seek treatment and regain control of my life.”

Campbell started with targeted antiperspirant for her palms and then medication, before trying Botox injections about five years ago.

“The first one worked for about four months, and that has gradually increased to about six months between treatments,” she says.

“The injections are a bit painful and there is a little bit of muscle weakness for a few weeks when you find it harder to open things like bottles or jars. That doesn’t worry me, but it might be a problem for somebody who works with their hands.”

Not everyone gets a positive outcome from Botox injections, however, and as with all treatments, even when they are successful the efficacy can vary.

Anand Sadacharam, a Malaysian engineer based in Kuala Lumpur, has also suffered extreme palmar hyperhidrosis since he was a teenager. He first sought medical help while studying business at Federation University in Ballarat.

“School was a challenge, especially the exams when I had massive dripping and had to keep wiping my pen with one of the hankies I carried every day,” he recalls.

“I was pretty timid then and didn’t even tell my mum, but she found out when she noticed my shorts were wet around the pocket area where I carried the hanky.”

Sadacharam, now 39, says the condition triggered many anxiety attacks during his youth and ended several relationships with women who could not deal with the constant sweating.

“My specialist recommended surgery [sympathectomy] but I wasn’t keen to go under the knife after I was told the excessive sweating would disappear on my hands but might relocate elsewhere,” he says.

“I tried Botox injections but found it an expensive patch-up procedure.”

He also tried herbal remedies but has now decided to manage his hyperhidrosis with inhibiting medication and a specific antiperspirant.

“It’s not easy, because as training manager there are a lot of hand gestures, handshakes and presentations, but I cover it with cotton gloves and tell the trainees I sweat a bit.

“My attitude changed as I grew older, thanks to the support I got from family and health professionals.”

Sadacharam has also found a partner “who has accepted me for who I am”.

Laughing, he adds, “I now take the attitude that it’s just sweat, not a killer zombie virus.”

This article was first published in the print edition of The Saturday Paper on Feb 20, 2021 as "Sweat and tears".

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Michele Tydd is an Illawarra-based freelance journalist.