An Essential Guide to Treating Excessive Sweating

Core Knowledge:

Excessive sweating most commonly begins in childhood or adolescence.

The most commonly affected areas are axillae (armpits), palms of the hands or soles of the feet as these areas have a high concentration of “sweat producing glands” called eccrine glands.  Symptoms are usually bilateral.  Excessive sweating can also be caused by certain medications or an underlying medical condition.

Sweating can be very distressing and embarrassing for the individual, and can also lead to difficulty in the workplace and performing certain tasks.

In practice the most common area for toxin treatment would be axillae although similar principles would apply in other areas, such as the groin.

Safety

Although the anatomy of the axilla is complex and there are important neurovascular structures to be aware of, the injection technique for anti-sweating treatment is extremely superficial and therefore with the correct technique there should be very few side effects

Anatomy

Unlike other areas where the aim is to reduce muscle movement leading to lines, for excessive sweating, the aim is to reduce sweat production from the eccrine glands. Botulinum toxin injections are effective due to their anticholinergic effects at the NMJ and in the postganglionic sympathetic cholinergic nerves in the sweat glands which lie subdermally.

Safety Margins

For the treatment to be effective, concentrate on the area most problematic for the individual.

If any doubt as to the diagnosis/location testing using iodine to perform a “sweat” test is possible, although in practice this is not often required if there is a clear history.

Iodine/Starch “Sweat” Test

Apply an iodine solution to the sweaty area.  Once it has dried, starch can be sprinkled on the area.  Areas of excess sweat would turn a dark blue colour over a period of around 10 minutes.

Desired Treatment Outcomes

Significant reduction in sweat production

Area Specific Consultation

Explore the history of the condition – has this been ongoing since childhood/adolescence?  Are the symptoms bilateral and which areas have they noticed is the most problematic.  Have they tried any treatments already?  What is particularly troubling them – may be embarrassed or other people may have noticed.  May be affecting ability to perform certain roles at work.

Explain the pros and cons of Botox – particularly that the effect will wear off after approximately 4-6 months.  They would need to have treatments every 4-6 months to maintain improvement.

Assessment:

Safety Margins

When marking up the axilla, generally a diamond pattern covers the majority of the affected area.  Ensure that injections are superficial

Avoid Veins:  Looking at the area in good light allows any obvious visible veins to be avoided in order to reduce bruising.

Pre-treatment preparation:

The area should be shaved and the client should abstain from using any antiperspirants or deodorants for 24 hours prior to the treatment

The axilla may be a sensitive area to inject and therefore using a topical anaesthetic such as LMX 30 minutes prior to treatment would reduce the discomfort for the client.

Injection Techniques

Mark out the axilla in a diamond shape and then divided this into 4 quarters.  Injections should be evenly distributed throughout the marked area, at approximately 1.5cm intervals.

Needle should be angled at approximately 30-45 degrees to the skin

Insert the needle with the bevel up approximately 2mm and deliver the required dose.  A small bleb should be seen, and if not this means the injection was not sufficiently superficial.

Withdraw and apply pressure if any sign of bleeding.

Common Follow-Up Indications

Unlike for clients having had cosmetic treatments, the main reason for follow up in this situation would be persisting sweating.  This could be confirmed using a sweat test if necessary.

If ongoing sweating is confirmed, additional injections may be required.  Using half the original dose in half the original areas may be a good starting point.

Bear in mind the total dose of Botox – maximum cumulative should not excess 400 allergan units in a 3 month periods

See a real treatment and consultation in action…

*Disclaimer – This guide is intended to serve as a reference point for delegates who have already completed the appropriate training in treating excessive sweating and should not be viewed as a replacement to practical learning.*