Almost 8 million Americans are estimated to suffer from hyperhidrosis. This guide to miraDry and other hyperhidrosis treatments explains how excessive sweating can be effectively addressed, and answers all the most frequently asked questions on this common medical concern.
What is hyperhidrosis?
Hyperhidrosis is the medical name for excessive sweating. Sometimes it is also called primary hyperhidrosis as opposed to secondary hyperhidrosis, which refers to perspiration that is caused by another medical condition.
Hyperhidrosis can occur in two basic forms — focal hyperhidrosis and general hyperhidrosis.
Focal hyperhidrosis causes excess sweating in one or two body parts. For example, the sweating may be excessive in the palm of the hands while normal sweating occurs elsewhere. The hands, feet, and underarms are particularly common sites for localized hyperhidrosis.
Excessive sweating that is limited to the underarm area is also called axillary hyperhidrosis, whereas excessive sweating of the hands or feet is known as palmoplantar hyperhidrosis.
General hyperhidrosis refers to excess sweating that occurs over much of the body.
How do the sweat glands works?
The sweat gland’s primary task is to regulate body temperature. All mammals, including humans, need to keep their body at a stable temperature. In humans, a normal temperature is 98.6°F (37°C) and even a variation of merely 2°F can cause a disturbance.
The body has a number of techniques for maintaining temperature. To cool off, it will shiver in an attempt to burn energy and raise the temperature. When the body becomes too hot, its primary defense is to release sweat. As the sweat evaporates, the body cools down.
A secondary function of sweating is to emit odors that telegraph emotions or sexual readiness; these signals developed before humans became civilized. These days, of course, people try to keep their body odors to a minimum as these smells are considered offensive to many.
There are three kinds of sweat glands in humans:
- Primary (eccrine) glands — The most common type of gland, the eccrine, is controlled by the central nervous system and secretes a watery substance whenever the body is at risk of a rising temperature. The glands are in the middle (dermal) layer of the skin and send a tube up to the skin’s surface, creating pores where perspiration appears. These glands are spread over almost the entire body, except for the lips, some genitalia and parts of the ears. They are most densely concentrated in the feet and hands. People with excessively sweaty palms have unusually active eccrine glands.
- Mature (apocrine) glands — Although present in the body from birth, these glands don’t become active until puberty. Once activated they secrete substances that are more complex and thicker than the eccrine secretions. Ear wax is one example of a substance resulting from an apocrine gland. They are found around the genitals and armpits, and can be the main source of the social discomfort associated with hyperhidrosis.
- Changed (apo-eccrine) glands — During puberty a number of the body’s original, functional glands undergo a transformation while roughly half of the glands associated with the armpit (axillary glands) become apo-eccrine. These glands still secrete a watery substance like eccrine glands, but can also carry the odors and substances of the apocrine glands.
How is excessive sweating diagnosed?
Hyperhidrosis typically includes two or more of the following traits.
- Bilateral sweating — The sweating is fairly evenly distributed on both sides of the body. Underarm perspiration should be more or less equal under both arms. If a person has sweaty palms, both hands are affected.
- Sweating interferes with daily activities — Sweating can force people to repeatedly change their clothes over the normal course of the day, make shaking hands unpleasant, cause embarrassing smells, and discourage sufferers from socializing.
- Frequency of episodes — A person may have one or more sweating episodes per week.
- Episodes begin before age 25 — The most common age for the condition’s onset is during the teen years, as a feature of puberty. It can begin sooner or later than that but after age 25, a change in sweating patterns may indicate another condition.
- A family history of hyperhidrosis — The condition may include a hereditary component.
- Focal hyperhidrosis stops during sleep — Overheating during sleep can cause sweating throughout the entire body, a natural response to a high temperature. However, localized sweating of the hands, feet, underarms, etc. should not occur while one is asleep and is a trait of hyperhidrosis.
The Hyperhidrosis Disease Severity Scale (HDSS) offers a standardized measure of the severity of excessive sweating. Which of the following statements best describes you?
- My sweating is never noticeable and never interferes with my daily activities.
- My sweating is tolerable but sometimes interferes with my daily activities.
- My sweating is barely tolerable and frequently interferes with my daily activities.
- My sweating is intolerable and always interferes with my daily activities.
The number beside the statement that best describes you is your score for hyperhidrosis. A score of 3 or 4 indicates severe hyperhidrosis. A rating of 2 indicates a mild condition.
A consultation with a physician can be invaluable in diagnosing hyperhidrosis. One critical task is to rule out a medical explanation for the sweating. Any examination for excess sweating must include a consideration of possible medical causes such as diabetes, hyperthyroidism, or endocarditis.
If the diagnosis is uncertain, a sweat test is sometimes given. Patients strip down to their undergarments and are covered with a dry powder that changes color in the presence of an acid, as sweat has a strong acid component. Two common powders used in the test are iodine and cornstarch (changes from brown to purple) and alizarin red (changes from yellow to dark red).
Once covered in powder, the patient sits in a sweat box like those found in certain gyms. In this test every person will sweat copiously, changing the color of the powder over wide areas, but extensive sweating on the palms of one’s hands is considered a mark of hyperhidrosis.
What are the causes and consequences of hyperhidrosis?
Folk explanations for excessive sweating tend to blame the condition on psychological factors like stress, anxiety, nervousness and even lying. These assumptions may be false but also self-fulfilling. Fearing the negative aspects of their condition, victims can become anxious, stressed or nervous, further aggravating their sweating.
Particularly disturbing is the fact that lie detectors (polygraph machines) measure sweat rate. In theory, a person can inform the test’s administrator of their hyperhidrosis so it will be taken into account when interpreting results; however, the fact that sweat levels are an element of the test indicates just how deeply sweat is associated with lying and dishonesty in our culture.
While the true cause of hyperhidrosis is uncertain, medical opinion focuses on the nervous system’s activity. Sweating is triggered by nerves that stimulate individual sweat glands. Too much stimulation leads to excessive sweating.
Along with social problems, hyperhidrosis can also cause medical problems. The most common are:
- Heat rash — While most common in babies, heat rashes also afflict adults whose pores become clogged. It can happen to anybody but is a special risk for people who sweat constantly. Loose clothing is the best way to reduce the occurrence of heat rash.
- Infections — Sweat that does not evaporate creates an environment where microbes can prosper. Feet, armpits and other covered parts of the body can become moist breeding grounds for things like toenail fungus, bacteria in sweaty hair and between the toes, and also the papilloma virus, which results in warts.
- Depression — The psychological impact of untreated hyperhidrosis can lead to withdrawal from society and depression.
What are the best first line treatments for excessive sweating?
Before trying expensive treatments, it makes sense to first see how much can be accomplished by trying some cost-effective solutions.
Deodorants are not particularly effective in treating hyperhidrosis, but antiperspirants with aluminum chloride can sometimes solve the problem. Start by trialling an over-the-counter antiperspirant such as Degree, Dove, or Secret. If that proves ineffective, move on to antiperspirants that require a prescription, such as Certain Dri or Drysol.
Results vary, and may cause skin irritation. Some people are stunned by how well antiperspirants works, while others are disappointed. There are also persistent rumors connecting aluminum to elevated risks for both Alzheimer’s disease and breast cancer, but thus far have no basis in fact.
Note that synthetic clothing fibers can cause excess sweating in some people. Shirts, shoes and socks made from natural materials are best. Wear loose fitting shirts and pants, leather shoes and soft, natural fiber socks when possible.
A special, anti-sweat undershirt called the Thompson Tee is available online for both men and women. It provides extra padding in the underarm region and is guaranteed to keep outer shirts and blouses dry.
What is miraDry?
Internet forums on skin disorders often feature questions from people with hyperhidrosis asking about one treatment or another. Invariably, most dermatologists and plastic surgeons advise, “Forget about treatment X. miraDry is the solution.”
miraDry is a treatment for axillary hyperhidrosis that uses microwaves to target and destroy sweat glands, without damaging other parts of the skin.
Although killing sweat glands may sound extreme, the effect of the procedure is similar to using an antiperspirant that lasts a lifetime. People need sweat glands, but they do not need all of them and can get along perfectly well without underarm glands. The treatment also puts an end to underarm odor.
Although this treatment is not suitable for people whose hyperhidrosis is limited to the hands, feet and/or forehead, it should at least be considered by anyone with heavy underarm sweating who is not satisfied with first-line treatments.
A pragmatic solution, miraDry lasts a lifetime and is approved by the FDA. It’s been used on tens of thousands of patients and has been widely shown to reduce underarm sweating by 80 to 85%.
Prior to the introduction of miraDry, more invasive surgical procedures were sometimes used to treat this condition. These included cutting out the sweat glands (excision), scraping out the glands (curettage), suctioning them (liposuction) and destroying the nerves that stimulate the sweat glands (endoscopic thoracic sympathectomy, or ETS).
Excision and ETS are no longer recommended, while the effectiveness of miraDry has made the other methods seem out of date. Laser techniques, at the forefront of technology for many other conditions, have less supportive evidence than miraDry.
How does miraDry work, and who is it for?
Most people with axillary hyperhidrosis are candidates for miraDry. Exceptions are people wearing electronic pacemakers for their heart or other implanted electronic devices. Patients with a history of intolerance to anesthesia like lidocaine and epinephrine should not have the treatment. Also, it should not be used on patients who depend on supplemental oxygen.
The procedure involves the following preparatory steps:
- The first step is to determine where the sweating occurs. The armpits are covered with an iodine solution and once it dries, cornstarch is applied over the iodine stain. The arms are kept above the head for a number of minutes while the powder changes color, turning dark purple in the sweaty areas.
- A picture is taken of the colored powder, creating a permanent record of the sweat glands’ location. Once the location has been identified, the top and bottom of the miraDry range is marked. The miraDry device will only be applied between these marks. The cornstarch is wiped off.
- Next, a grid is created between the markers. The miraDry device uses these markers as a guide to ensure that the entire range is treated.
- A pain blocker (lidocaine is commonly used) is injected during the procedure to locate the glands. Due to the number of injections required and the discomfort that can be associated with them, this is generally the worst part of the procedure.
Once these steps have been completed, the actual treatment can begin.
The miraDry apparatus includes an electronic monitor that displays the grid drawn on the patient’s arm, ensuring that the entire marked range is treated. The device is placed over each area on the grid for about 20 seconds. During this process the patient may feel a sucking sensation as the skin is drawn toward the handpiece.
The device itself resembles the handle of a professional-grade blow dryer, but instead of a long tube it has a flat opening that the doctor places against the underarm. The microwave effects are felt from 2 mm – 5 mm below the skin. At the same time, the blower cools the skin surface to prevent damage while the sweat glands are being destroyed.
The procedure takes about 20 minutes per armpit. Before using the device on the second armpit, an ice pack is applied to the first. If the treatment begins to feel hot, the patient should speak up, as more numbing may be required.
What are miraDry’s potential side effects?
The procedure leaves the armpits red and swollen. Regular use of ice packs and over-the-counter painkillers is recommended for the first several days. It is best to schedule the treatment for a date when you have no plans for the coming week.
It takes several weeks for the swelling and bruising to disappear. After a month, a patient should be in good shape and notice that the sweat under their armpits has been greatly reduced.
Note that a second miraDry treatment three months after the first is sometimes necessary to completely eliminate all underarm sweating and, in extreme cases, a third application may also be required.
The immediate post-treatment side effects (e.g., swelling and numbness) are usually short-lived. Only very rarely does the numbness persist.
Chicago-based plastic surgeon Dr. Gregory Turowski reports that one long-lasting common (and welcome) side effect is a decrease in armpit hair. Other common side effects and typical recovery periods reported by Dr. Turowski are:
- Swelling in the treated area (1-8 weeks)
- Soreness, discomfort or tenderness (2-3 weeks)
- Altered sensation in and around the treatment area (1-12 weeks)
- Redness from the apparatus suction (2-3 days)
- Bruising at the injection sites (2-3 days)
- Bumps or lumping in the armpit (4-6 weeks)
The doctor also reports some less common side effects:
- Swelling in adjacent arm or torso (1 week)
- Hyperpigmentation (up to 8 weeks)
- Soreness in arm or shoulder due to procedure positioning (2-3 days)
- Numbness or tingling in arm due to anesthesia (less than one day)
- Feeling like there is a tight band gripping the treated area (up to 8 weeks)
- Small blisters or rashes in the treated area (2-3 weeks)
Can Botox be used for sweating?
Botox is a protein that deadens nerve cells, inactivating them for a period of months. While best known as a treatment for facial wrinkles, Botox injections can also be used to disrupt the nerve signals that activate sweat glands. Theoretically, it should work to reduce sweat on any part of the body, but the most satisfying results appear to be in the underarm area.
Injecting Botox is typically a safe, relatively painless procedure. The most disturbing aspect may be the number of injections required. A small dosage is inserted per injection, making multiple injections necessary. The nervous system coordinates many body activities — when injecting Botox for hyperhidrosis, the physician must be careful to avoid paralyzing any muscles.
A follow-up visit to your doctor one or two weeks after treatment allows for “touch-up” injections if there are any areas where perspiration has not been significantly reduced.
- Armpits — About 20 to 25 injections are made under each arm. Typically, sweating under the arms is reduced by 80% or more with the effect lasting up to six months or longer. Underarm treatment is the most common use of Botox for hyperhidrosis.
- Palms — Multiple Botox injections are delivered to the palm and fingers. This procedure can also last for six months. There is a major risk, however, as the hands are rich in muscles that allow for fine motor control. Botox can paralyze some of these muscles, weakening the hand and making it difficult to perform delicate maneuvers.
- Feet — Although in theory Botox injections can be used on the feet, the practical results are often disappointing. The injections themselves seem to be more painful and sweating is not reduced as much as in the armpits or palms.
- Forehead — Be sure your physician is well-experienced in forehead injections for hyperhidrosis. It’s easy to accidentally paralyze muscles.
What is iontophoresis?
Iontophoresis is a home-care procedure that uses electricity to reduce sweating, particularly in the hands and feet. While it sounds a bit dangerous — people place their hands or feet into water that has electricity running through it – the method has been used for over 60 years and has been proven safe and effective.
The most significant risk is a burn on the treated part of the body, but unless you are using a homemade iontophoresis kit, the risk is minimal.
There are a number of kits available. Most come with pans for the water, electrodes for the pans and a series of cables and plugs. There are also machines that are labeled iontophoresis devices but do not work in the time-tested manner. Examples of traditional kits are:
- Galvan DE 20 and DE 20 G — Comes in a carry kit. The DE 20 G device has continuous current only while the other kit allows choice of continuous or pulsed current.
- Iontoderma — Comes in a carry kit. Continuous current only. At $399 per unit, it is less expensive than devices with more features.
- Saalio — Allows for a continuous or pulsed current. Has special accessories for treating underarms.
- SwiSto3 — Much like the Saalio, this device allows continuous or pulsed current, and has special accessories for treating underarms.
Iontophoresis kits use a current to introduce ions into the body, blocking the sweat glands. Known as tap water iontophoresis (TWI) devices, they were already on the market when, in 1976, the FDA began regulating medical devices. In 1983 new regulations allowed only a few TWI devices to remain on the market, but in 2014 the FDA investigated TWIs again and eased up on their restrictions.
Treat your hands and/or feet in accordance with kit instructions. Repeat every other day until you reach a satisfactory level of dryness, and then once a week. The reduction in sweating continues indefinitely if the procedure is maintained.
Note that iontophoresis is not recommended for pregnant women or people with electronic pacemakers or metal implants.
How do anticholinergics work?
These are oral medications that block certain signals in the nervous system that trigger glandular secretions and control muscle behavior. They were not developed to treat hyperhidrosis, but are sometimes prescribed for the condition as they have proven to be effective in some cases.
The side-effects, however, can be troubling. In elderly patients over 65, these medications appear to increase the risk of Alzheimer’s disease. Many of the other side effects are considered mild in comparison but can include dry mouth, constipation and heart palpitations.
Anticholinergics belong to a class of drugs that include:
- Benztropine (Cogentin) — Developed as a drug for Parkinson’s disease. Treatment for hyperhidrosis is an off-label use, reported effective in only one out of every eight people.
- Glycopyrrolate (Robinul, Cuvposa, Glycate) — Used in children to treat drooling caused by cerebral palsy. Used in adults to treat peptic ulcers, with a noticeable side effect of suppressing perspiration. Treatment for hyperhidrosis is off-label, but considered safe and effective.
- Oxybutynin (Ditropan XL, Oxytrol) — Developed to treat urinary spasms. As an off-label use, treatment for general hyperhidrosis is considered effective but a common side effect, dry mouth, is often bothersome.
- Propantheline (generic drug) — Developed to calm an overactive stomach. An off-label use is for sweaty hands and feet. It has some notable side effects (besides decreased sweating), including dry mouth, dizziness, drowsiness, nausea and excitement.
Is it safe to use medication for an off-label condition?
Medications are approved by the FDA for specific conditions; however, doctors are free to prescribe them to treat other conditions. These secondary prescriptions are called off-label. The most common reason for an off-label prescription is to achieve a side effect of the primary usage. For example, medications that decrease sweating as a side effect may be prescribed to treat hyperhidrosis.
There is always some risk in an off-label prescription because the drug has not undergone the extensive testing for safety, effectiveness and dosage effects that the FDA require when approving the drug for its primary uses. Doctors, however, may have ample clinical experience with an off-label application and find it safe and effective.
Be sure to have a full discussion with your physician whenever taking any medication, especially if its use is off-label.
What is laser sweat ablation?
Laser surgery is also available for treating underarm sweat. Like miraDry, lasers destroy the sweat glands so they do not grow back.
The procedure involves making a small incision in the armpit, inserting a flexible fiber under the skin, and moving the probe so that the glands are heated and destroyed. The incision is normally small enough to allow for a skin glue rather than a stitch.
The procedure produces some temporary swelling and bruising.
Can Ultherapy be used for hyperhidrosis?
Ultherapy uses ultrasound and was developed as a skin-tightening device for the face and neck. It has also been used to treat hyperhidrosis, although the FDA has not approved its use for this purpose.
Sometimes patients are treated with a combination of miraDry and Ultherapy, making it unclear where to attribute the positive results.
Which hyperhidrois treatment works best?
With so many treatments available it may seem difficult to select one.
The main methods are:
- Blocking pores — Plugging the passageway between skin pore and sweat gland. Antiperspirants and iontophoresis kits are used in this case.
- Blocking nerves — The nervous system signals a gland to start secreting sweat. Botox and anticholinergics use this method.
- Destroying sweat glands — miraDry, laser ablation and Ultherapy all destroy some sweat glands.
Every treatment choice demands trade-offs. Blocking pores is the least expensive method but also has the shortest lasting results. Blocking nerves lasts longer but costs more. Destroying sweat glands is the most expensive treatment and has the longest recovery period, but is permanent. Once it’s done, the sweat glands are gone forever.
The list below outlines the differences between these approaches.
Area of treatment: Underarms
Term of relief: Permanent
Side effects: Temporary swelling, bruising, soreness
Area of treatment: Underarms
Term of relief: Permanent
Side effects: Temporary swelling, redness
Cost: approximately $3,000
Area of treatment: Underarms
Term of relief: Permanent
Side effects: Temporary soreness or tenderness in treated area
Cost: $2,000 to $4,000
Area of treatment: Underarms, hands, forehead
Term of relief: 4-6 months
Side effects: Possible swelling, bruising, paralysis
Cost: $1,000 to $1,500 for both armpits
Area of treatment: Hands, feet
Term of relief: 1 week
Side effects: Burn (but very unlikely)
Cost: $400 to $1,000 for a kit
Area of treatment: General
Term of relief: Short term
Side effects: Heart palpitations, dry mouth, constipation depending on medication used
Cost: $530 for 16 ounces of Cuvposa oral medication (approx. 3 month supply)
Area of treatment: Underarms
Term of relief: Short term
Side effects: Skin irritations
Cost: $10 to $20 for 2 ounces
Area of treatment: Underarms
Term of relief: Short term
Side effects: None
Is miraDry worth the cost?
It depends on how severe your axillary hyperhidrosis is. If it can be successfully controlled using antiperspirants, then that is usually your best solution. If something else is required, the basic choice is between Botox and miraDry.
Botox is cheaper, but must be repeated. If the treatment is kept up regularly, it will cost more than miraDry. Paying the miraDry price makes sense if you can afford it and if your condition is unbearable.
Isn’t it dangerous to eliminate sweat glands?
Although the loss of a major portion of the sweat glands would be catastrophic, the average human body has about 4 million sweat glands, with only about 2% of them situated in the armpits.
Even if a miraDry or Botox treatment is completely effective at destroying or decommissioning underarm sweat glands, the body has an ample supply of these glands to keep body temperature in the normal range.
If I stop sweating in one place, will I sweat more in another area?
There is a phenomenon called compensatory sweating which was a common side effect of endoscopic thoracic sympathectomy (ETS), a procedure that is no longer recommended.
Therefore increased sweating in another area as a response to treatment is highly unlikely.
Are there any treatments to reduce sweating everywhere?
Don’t forget that we all need to sweat as a way of regulating body temperature. Ending all sweating would be dangerous to one’s health. Even patients with general hyperhidrosis are advised to limit the areas they treat.
Because underarm sweating produces noticeable stains and odor, many surgeons recommend miraDry for their patients who sweat all over. If sweating on hands and/or feet remains a problem, a home iontophoresis kit offers additional help with sweat reduction.
Anticholinergics will reduce sweating across the whole body, but before using these medications for hyperhidrosis, patients should have a thorough discussion with their doctor about possible side effects.
Are there any natural treatments for excessive sweating?
While some herbal teas are reputed to help hyperhidrosis, as of yet no substantial testing has been performed to certify their results.
Some people swear by sage tea. Place 3 ounces of sage leaves into a cup of boiling water and let steep for 15 minutes. Drink 3 times per day. Although a cup now and then is unlikely to do a person any harm, prolonged use of sage tea can damage the liver and nervous system.
Many internet tips on lifestyle changes that can reduce sweating assume the problem is psychological, reflecting nervousness or anxiety. This assumption carries little weight with doctors who have heard patient upon patient tell similar stories: “It started when I was in middle school. I began sweating heavily and have been embarrassed by it ever since.”
Psychological responses to the sweat may sometimes enhance the hyperhidrosis, but medical science has strong evidence that hyperhidrosis is a physical condition that commonly begins around puberty.
Are hyperhidrosis treatments covered by insurance?
Insurance companies are reluctant to cover hyperhidrosis treatments. However, they may consent if your doctor can provide evidence that less expensive treatments failed or if you can provide a referral from a psychiatrist describing the impact of the condition on your psychological well-being.