Management of axillary hyperhidrosis for a better quality of life

Hiperhidrosis exceso sudoración

Axillary hyperhidrosis is excessive sweating originating in the armpits. It is not uncommon to see these patients in consultation. The importance of this disorder is the decrease in the quality of life with impact on personal relationships and work environment.

It is usually found in patients with no other associated disorder (primary hyperhidrosis). The cause is the excess production of sweat in the sweat gland. It is not well known why this occurs. Symptoms may appear unpredictably, with activities that would not normally produce this response. We know that emotional stress can aggravate or trigger it.

Management is complex, although fortunately there are several topical, systemic and even surgical treatments available. The type of treatment should be individualized and is guided by criteria such as age, intensity of symptoms or personal or occupational repercussions.

Topical antiperspirants are the first therapeutic measure, especially in mild cases. These are over-the-counter products containing mineral salts (such as aluminum salts) in varying concentrations. They can have different presentations (cream, lotion, roll on). They act by blocking the outflow of sweat from the sweat gland, but do not prevent sweating. Skin irritation is a well-known adverse effect, but it can be minimized by using the product at night, with dry skin, and regulating the number of applications and concentration of salts, according to efficacy and tolerance. Traditionally there has been concern about the relationship between the use of axillary antiperspirants and breast cancer, but so far no causal relationship has been demonstrated.

Another topical treatment available is topical anticholinergics. These are substances that block the passage of neuronal information that triggers the sweating stimulus, thus decreasing sweating. One of them is topical glycopyrronium: it is approved in Spain for use in axillary hyperhidrosis and has been shown to reduce sweating and improve quality of life. It has been associated with good tolerance and mild adverse effects. It is interesting to know that there are studies in children between 9 and 16 years of age in which its efficacy and safety have also been proven. Until recently it had to be formulated, but as of 2023 we have the marketed pharmaceutical product developed by a laboratory.

Another topical anticholinergic treatment is oxybutynin. It is available in Spain in the form of a transdermal patch and is indicated (according to the technical data sheet) for other pathologies. For hyperhidrosis it can be administered as a patch or formulated as a gel or emulsion-gel. It has been shown in studies to improve sweating and quality of life in both adults and children. But it is not an approved treatment at the moment and no marketed product is available for this indication.

There are also oral options, such as oral oxybutynin. It is indicated in other pathologies, but has demonstrated efficacy in reducing sweating. It is often accompanied by side effects such as constipation or dry mouth. It would be more indicated in hyperhidrosis affecting several body areas.

One of the best known treatments is botulinum toxin infiltration. It acts by blocking the release of acetylcholine (the biochemical messenger that triggers sweating) at the junction between the nerve fibers and the sweat gland. It is an excellent treatment for the axillary region and the duration of effect is usually 6 to 8 months. The procedure is performed on an outpatient basis (no hospitalization is required), it is a non-invasive and virtually painless treatment. Anesthetic cream is applied beforehand to eliminate possible discomfort.

Another treatment available for axillary hyperhidrosis is microwave thermolysis. It is performed with a device that destroys the eccrine glands by means of heat. The procedure is also performed on an outpatient basis and requires prior local anesthesia. It is noteworthy that the effect is maintained in the long term.

As a last option, we have surgery. Transthoracic sympathectomy removes the nerve centers responsible for sweating. The procedure has evolved significantly and is performed in a minimally invasive manner. The most relevant side effect is compensatory hyperhidrosis, i.e., increased sweating in other areas such as the back or extremities.

Dr. Beatriz Fleta