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Dr Thomas Poyner, a founder member of the Primary Care Dermatology Society, passes on his tips for managing patients suffering from excessive sweating ­ Dr Poyner is honorary lecturer in the School of Health, University of Durham, and a GP in Stockton-on-Tees

1. It is important to ask the patient what they mean by excessive sweating. Is it generalised, or is it localised to the axillae, hands or feet? It is vital to find out how the sweating affects them. Key questions to ask should include what the patient's occupation and hobbies are.

2. Localised hyperhidrosis can run in families. Excessive sweating can occur in thyrotoxicosis and it is worth requesting TFTs. Patients with systemic disease such as lymphoma and TB can complain of increased sweating. Investigations that might be useful include an FBC & ESR, CRP, LFTs, RBS and CXR.

3. Damp armpits are a source of embarrassment, especially visible damp clothing. Wearing loose-fitting garments and choosing fabrics that do not stain can be helpful. Frequent washing with a mild antiseptic can reduce any odour. Replacing soap with emollients can reduce irritation. Excessive sweating in the axillae can predispose to intertrigo.

4. Patients with pitted keratolysis of the feet have moist malodorous feet with pits on the soles. Alternating pairs of shoes, having a different pair each day, allows the shoes to dry out. Wearing special absorbent insoles can also be helpful.

5. Topical preparations of aluminium chloride hexahydrate can be a useful first-line treatment. Licensed for axillae, palms and soles, they tend to be most effective in the axillae. In the axillae they should be applied to dry skin in the evening and washed off next morning. They can irritate and can be alternated with a morning application of 1 per cent hydrocortisone cream.

6. In iontophoresis a low-voltage electric current is used to reduce sweating of the hands. The hands are immersed in tap water through which flows a low-voltage electrical current. The patient can undergo an initial course of treatment at a dermatology department. They then need intermittent therapy ­ either at the dermatology department, or by purchasing their own machine.

7. Botulinum type A toxin is a bacterial toxin that decreases sweating by blocking acetylcholine. It is licensed as a treatment for severe axillary hyperhidrosis. The treatment is injected locally. The treatment needs to be repeated at approximately 18-month intervals.

8. For very difficult cases of palmar hyperhidrosis a sympathectomy is a possibility. This is performed by an endoscopic approach. A compensatory hyperhidrosis at another site is quite common. There is the risk of significant complications including Horner's syndrome, pneumothorax and phrenic nerve damage.

9. Oral anticholinergics such as propantheline have been prescribed for hyperhidrosis. However, side-effects such as dry mouth and blurred vision have limited their use. betablockers have also been tried for those whose sweating is associated with anxiety.

10. There is tremendous variability in the availability of treatment. Some dermatology departments can provide iontophoresis. Endoscopic sympathectomy is done in tertiary centres. Those wishing to provide a botulinium toxin service can go on training courses. The availability of

this treatment on the NHS depends

on local circumstances.

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