Perspiration and Body Odour

Perspiration and Body Odour

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Perspiration and Body Odour Nancy Kleiman, BSP, MBA Date of Revision: September 2014

Pathophysiology

Sweating is essential for regulating body temperature. Sweat production increases in response to an increase in the body temperature and produces a cooling of the body.1 Normal body temperature is regulated through receptors in the hypothalamus, which monitor the core temperature and skin receptors that monitor the external temperature. Sweat glands consist of a secretory coil in the dermis and a duct that transports sweat to the skin surface (Figure 1). Failure of this regulating system to reduce body heat can lead to heat exhaustion, heat stroke, hyperthermia and in extreme cases death.2 Excessive local or systemic sweating is called hyperhidrosis and can be socially and psychologically disabling.3 There are 3 main types of sweat glands: eccrine, apocrine and apoeccrine.2 Eccrine sweat glands are primarily responsible for body cooling. They cover the skin surface with the greatest numbers on the palms of the hands and the soles of the feet as well as the face, head and trunk. Eccrine sweat is primarily hypotonic (sodium, chloride and bicarbonate are reabsorbed through the eccrine duct) which conserves electrolytes during excessive sweating.2 Apocrine glands are larger than eccrine glands, open into hair follicles and are primarily found in the underarm, nipple and genital areas.2 Apocrine glands become functional at the time of puberty. Apocrine sweat is a milky, viscid, odourless secretion containing fatty substances, but develops an odour once it reaches the skin's surface.

Apoeccrine glands have structural features of both eccrine and apocrine glands. Like the eccrine gland, they have a long duct and open directly onto the skin's surface. They are found only in the underarm area of adults and also develop at puberty. Apoeccrine glands secrete nearly 10 times as much sweat as eccrine glands do.2 Figure 1: The Skin

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Physiologic sweating is a natural reaction to thermal and emotional stimuli. Hot environments, over-clothing and exercise all trigger the hypothalamic sweat centre to increase heat loss through cutaneous vasodilation and generalized sweat production, especially on the face and trunk. Sweating around the lips and forehead is a physiologic response to eating hot or spicy foods. Emotional stimuli such as anxiety, embarrassment, fear, anger, excitement or mental stress can cause sweating from the palms, soles, underarms and forehead.4 Hyperhidrosis is defined as excessive sweating beyond that required for body cooling. It is estimated to affect about 1% of the general population and is referred to as primary or secondary.3 Primary focal hyperhidrosis refers to excessive sweating of one body part. The cause is unknown and it commonly affects the axillae, palms, soles and the craniofacial region. Axillary hyperhidrosis typically appears during adolescence while palmar hyperhidrosis can occur during childhood.1,5

Secondary hyperhidrosis is more generalized and occurs over the entire body. It is typically associated with endocrine diseases such as diabetes, hyperthyroidism, obesity and menopausal change but can also occur in respiratory failure, chronic infectious diseases, some psychiatric disorders, malignancy, fever, and alcohol or drug withdrawal.1,3,6 Hyperhidrosis may also be secondary to the use of medications such as ASA, insulin, morphine, fluoxetine and acetaminophen.3,6 Hyperhidrosis is not usually associated with odour but can be excessive to the point of affecting a person's quality of life (e.g., cold sweat is dripping off the hands or face and damaging papers or books; clothing can become wet leading to an increased risk of infection because of the constant dampness in a concentrated area of the skin).3 Bromhidrosis refers to sweat that has an offensive odour and is a chronic condition. Sweat from the eccrine glands is usually odourless, although occasionally excretion in sweat of odour-causing chemicals like garlic, onions and fish can produce an odour. Body odour is generally produced by the action of bacterial decomposition of fatty substances in apocrine sweat. The odour produced from feet is often associated with footwear that does not allow air to circulate, causing excessive sweating and the growth of bacteria.3 Predisposing factors for bromhidrosis include hyperhidrosis, obesity and poor body hygiene.1

Goals of Therapy

Control socially undesirable body odour

Control underarm wetness resulting from normal, physiologic sweating

Reduce the quantity of sweat excretion in hyperhidrosis to a tolerable level that permits participation in work and social situations Prevent complications of hyperhidrosis involving the feet—odour, blisters and skin infection

Patient Assessment

Concerns about body odour and underarm wetness resulting from normal, physiologic sweating often can be managed without physician referral. Refer patients with excessive sweating that has not been controlled with regular use of antiperspirants or deodorants, increased sweating of recent onset in adults or sweating that occurs in an unusual pattern with no explanation. The patient should be assessed in order to eliminate neurologic (spinal injuries, Parkinson's), cardiovascular (heart failure), endocrinologic or metabolic disorders (hyperthyroidism, diabetes,

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menopause) as well as medications that may cause excessive sweating (see Secondary Hyperhidrosis above).3 Sweat production can be assessed by a simple starch-iodine test that identifies areas of concern. An iodine solution is applied to the area of skin to be evaluated, and left to dry. A starch (potato or corn) is sprinkled over the area being tested. Sweat will produce a dark blue discoloration. This process can be repeated after several weeks to identify areas of improvement and areas that need further treatment.7 An assessment plan for patients with perspiration-related complaints is presented in Figure 2. Figure 2: Assessment of Patients with Perspiration and/or Body Odour Complaints

Nonpharmacologic Therapy General Measures

3,4

Wear natural fibres that are more breathable than synthetics and cool, porous clothing, particularly in the underarm area. If possible, avoid activities known to produce excessive sweating, such as certain stressful situations or exercising in hot weather. Water and electrolytes lost through excessive sweating should be replaced regularly. Underarm shields primarily act as barriers and absorb sweat, preventing wetness from staining clothing. If underarm skin is irritated, avoid soap products that cause further irritation and use unscented cleansers instead.

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To manage body odour, a regular bath or shower using soap and water will help to prevent build-up of bacteria, sweat and dead skin cells that interact to produce body odour. A daily bath or shower may be necessary for some people. When a full bath or shower is not possible, sponging in the underarm and genital areas can help control the major source of body odour. Shaving the armpits can reduce the propagation of body odour by reducing the surface area for bacterial action. Avoid wearing clothing made from synthetic fabrics to decrease sweating and therefore body odour. Wash clothing in hot water to remove body odour before wearing again.3

Foot Care

Foot care is important for patients with excessive foot sweating (plantar hyperhydrosis) and/or odour. Feet should be washed regularly using a skin cleanser and dried thoroughly. Daily washing may be needed for odour control followed by application of an absorbent foot powder twice a day. Non-occlusive footwear made of natural materials, such as leather shoes or sandals, should be worn with cotton or wool socks. Alternating with different pairs of shoes each day will allow them to dry thoroughly. Socks should be changed twice daily to ensure the feet remain dry and are not at risk of fungal infections (athlete's foot).3 See Athlete's Foot.

Iontophoresis

Iontophoresis uses a special water bath apparatus to introduce a mild electrical current of soluble ions into the skin: thought to work by blocking the sweat ducts at the skin surface or by inducing an electrical change in the sweat glands and disrupting secretion.3 Iontophoresis is often used for hyperhidrosis of the hands and feet not responding to conservative therapy.3 Commercially available devices can be used at home. The process is time consuming and not practical for some, depending on the area being treated.1 Side effects are minor and consist of dry or cracked skin, tingling or burning and rarely redness and small blisters. If any of these side effects occur, the voltage can be decreased. An emollient can be applied for dry skin or hydrocortisone 0.5% can be used to treat redness.3 Iontophoresis in contraindicated in anyone who is pregnant, has an orthopedic prosthesis or has a pacemaker.7

Surgery

Surgery is considered only when all other options for treatment including topical, systemic or botulinum toxin have failed (see Pharmacologic Therapy). Axillary vault excision removes or destroys as many eccrine sweat glands as possible. A second method, endoscopic thoracic sympathectomy (ETS) cuts the sympathetic chain abolishing sweating but leaves the eccrine glands intact. A disadvantage of this irreversible procedure is that hyperhidrosis may be induced in other areas of the body, which can be worse than the original condition.3,7

Pharmacologic Therapy Nonprescription Therapy

The most common nonprescription agents used to manage perspiration and body odour problems are antiperspirants and deodorants as described in Table 1. The mainstay of treatment is daily use of antiperspirants as part of a personal hygiene regimen. Antiperspirants reduce sweating by either mechanically obstructing the eccrine gland pores, causing the sweat to thicken and clump or by causing atrophy of the secretory cells.1,3 The most commonly used antiperspirants contain various types of aluminum salts. Skin irritation is the most common side effect and may be caused by the active ingredient, or by perfumes or preservatives used as additives.3 Aluminum chloride is used in the treatment of hyperhidrosis when regular nonprescription products do not control symptoms effectively. It is applied at night when sweat glands are less active, and washed off in the morning to prevent skin irritation. Initially the product is applied every 24–48 hours until the condition is controlled, at which time application every 1–3 weeks can be considered.3 Aluminum was thought to contribute to Alzheimer's disease and other types of dementia. Research has shown that

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there is no definite connection between aluminum-containing products and Alzheimer's disease.8 There is also no conclusive evidence showing an association between aluminum and breast cancer.9 Deodorants do not prevent sweating but mask body odour by reducing the bacterial population in the area. Aluminum- or zinc-containing deodorants have antibacterial action. Alum has been used traditionally as a water purifier. “Natural or crystal” deodorants usually contain potassium alum or ammonium alum crystals. Other products that have been used as deodorants are vinegar, sodium bicarbonate and isopropyl alcohol.3 Products used to control foot odour contain combinations of zinc oxide, sodium bicarbonate, corn starch, some aluminum and alcohol. Formaldehyde, glutaraldehyde and tannic acid were once used to treat hyperhidrosis by plugging the pores. These chemicals are no longer used because of contact sensitivity with formaldehyde and skin discoloration from glutaraldehyde and tannic acid.3 Table 1: Nonprescription Management of Perspiration and Body Odour

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For product selection, consult Compendium of Products for Minor Ailments. Antiperspirant and Deodorant Products. Class

Product

Action

Uses

Comments

Deodorants

potassium alum ammonium alum

Act as powerful astringents or drying agents.

Used daily to control sweating and body odour.

Available as roll-on deodorants for underarm use (alum products) and as “natural crystal” deodorants that are moistened and rubbed onto the underarm area. Can cause local irritation.

Deodorants

zinc oxide, water soluble zinc salts (zinc chloride, zinc gluconate, zinc lactate), corn starch

Act as drying agents.

Use daily to control excess sweating and odour on feet.

Foot powders and sprays (zinc oxide, corn starch).

various aluminum salts and related compounds (e.g., aluminum chlorohydrate, aluminum-zirconium tetrachlorohydrex)

Thickens the sweat which clumps and blocks sweat gland pores, preventing sweat from reaching the skin's surface.

Mild hyperhidrosis: Used daily as part of a personal hygiene regimen.

Skin irritation, burning, stinging or rashes may occur because of the active ingredient, perfumes or preservatives that have been added. Avoid applying to freshly shaved or abraded skin as skin irritation can occur.

aluminum chloride (e.g., DrySol 20%, Certain Dri 12%)

Thickens the sweat which clumps and

Use in the treatment of moderate to

Contains ethyl alcohol as a vehicle. Localized burning

Antiperspirants

Antiperspirants

Absorb odour.

Available in a number of formulations such as roll-on, sticks or sprays.

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For product selection, consult Compendium of Products for Minor Ailments. Antiperspirant and Deodorant Products. Class

Product

Action

Uses

Comments

blocks sweat gland pores, preventing sweat from reaching the skin's surface.

severe hyperhidrosis.

and skin irritation are common.

Applied to dry skin nightly until desired effect reached then 2–3 times per week. Available as a roll-on or liquid formulation.

Damage to clothing is possible.

Avoid applying to freshly shaved or abraded skin as skin irritation can occur.

Prescription Therapy

Systemic drug therapy (anticholinergics) is the only option for the treatment of generalized debilitating hyperhidrosis that has not been controlled with the usual topical treatments. Systemic anticholinergics such as oxybutynin, glycopyrrolate and propantheline bromide are most commonly used although this is not a Health Canada-approved indication.3,11 Side effects include blurred vision, sedation, urinary retention and constipation.3,11 Botulinum toxin injection into the axilla blocks the release of acetylcholine from cholinergic fibres and is beneficial in the treatment of hyperhidrosis. It is used as first-line treatment for moderate to severe conditions or for milder cases when topical treatment has failed after 1 month of continuous treatment.11 Sweat reduction should be noticed after 2–4 days and should be significant after 2 weeks.11 The procedure consists of a number of injections and the effects last from 4–8 months. It is painful and expensive.3 Use of botulinum A toxin is contraindicated in pregnancy and breastfeeding, neuromuscular disorders and with some medications (quinine, calcium channel blockers).

Monitoring of Therapy

Table 2 provides a monitoring plan framework which should be individualized. Table 2: Monitoring Therapy for Perspiration and Body Odour Symptom

Monitoring

End Point

Actions

Underarm wetness

Monitor daily for 2–3 weeks while using nonprescription antiperspirants as well as a daily personal hygiene routine.

Dry axillae in resting, non-stressed state at comfortable room temperature after 2–3 weeks of intervention.

If aluminum chloride effective, reduce frequency to level required to maintain effect.

If patient cannot tolerate aluminum chloride products (mild or stronger strengths) or is not responding after a 2–3 week treatment trial, refer to a physician for other treatment options. See Figure 2.

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Symptom

Monitoring

End Point

Actions

Hand sweating

Monitor daily while using conventional nonprescription antiperspirants containing aluminum applied to the palms of the hands for 1–3 weeks.

Hand sweating reduced to a tolerable level after 4 weeks of intervention.

If hand sweating interferes with social or occupational activities, refer to a physician.

Monitor daily while using a regular foot care routine including nonpharmacologic therapy as indicated previously.

Foot sweating reduced to a tolerable level after 3 weeks of treatment.

If patient cannot tolerate nonprescription products containing aluminum chloride or is not responding to treatment after a 3-week trial, refer to a physician for other treatment options. See Figure 2.

Body odour

Monitor daily while using a personal hygiene routine that includes washing with soap and water, changing clothing as required and regular use of aluminum-containing antiperspirants.

Offensive body odour eliminated after 1–2 weeks of intervention.

If personal hygiene measures and antiperspirants are ineffective after 1–2 weeks, refer to a physician for other treatment options. See Figure 2.

Skin irritation from antiperspirants

Ensure correct use and if irritation continues, use a different brand or a lower concentration aluminum product or a deodorant that is aluminum-free.

Antiperspirant tolerated with minimal or no irritation.

If irritation continues, stop antiperspirant and refer to physician for other treatment options. See Figure 2.

Foot sweating

Monitor daily for 1–3 weeks while using aluminum products or absorbent foot powders.

Treat symptomatically with 0.5% hydrocortisone cream twice daily for no more than 14 days if irritation severe.

If patient cannot tolerate aluminum chloride or is not responding after a 3-week trial, refer to a physician for other treatment options. See Figure 2.

Prescription therapy may be necessary for severely irritated skin.

Suggested Readings

Clark C. Sweating and hyperhidrosis. Pharmaceutical J 2006;276:757-60. Nyamekye I. Current therapeutic options for treating primary hyperhidrosis. Eur J Vasc Endovasc Surg 2004;27:571-6. Pariser DM, Ballard A. Topical therapies in hyperhidrosis care. Dermatol Clin 2014;32:485-90. Schlereth T, Dieterich M, Birklein F. Hyperhidrosis–causes and treatment of enhanced sweating. Dtsch Arztebl Int 2009;106:32-7.

References

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1. Nyamekye I. Current therapeutic options for treating primary hyperhidrosis. Eur J Vasc Endovasc Surg 2004;27:571-6. 2. Mauro T, Goldsmith L. Biology of eccrine, apocrine and apoeccrine sweat glands. In: McGraw-Hill AccessMedicine. Dermatology. Subscription required. Accessed June 18, 2009. 3. Clark C. Sweating and hyperhidrosis. Pharmaceutical J 2006;276:757-60. 4. Leung AK, Chan PY, Choi MC. Hyperhidrosis. Int J Dermatol 1999;38:561-7. 5. Hornberger J, Grimes K, Naumann M et al. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol 2004;51:274-86. 6. Paisley AN, Buckler HM et al. Investigating secondary hyperhidrosis. BMJ 2010;341:c4475. 7. Wang R, Solish N, Murray CA. Primary focal hyperhidrosis: diagnosis and management. Dermatol Nurs 2008;20:467-70. 8. Exley C. Does antiperspirant use increase the risk of aluminum-related disease, including Alzheimer's disease? Mol Med Today 1998;4:107-9. 9. Darbre PD. Aluminum, antiperspirants and breast cancer. J Inorg Biochem 2005;99:1912-9. 10. Kanlayavattanakul M, Lourith N. Body malodours and their topical treatment agents. Int J Cosmet Sci 2011;33:298-311. 11. Gee S, Yamauchi PS. Non-surgical management of hyperhydrosis. Thorac Surg Clin 2008;18:141-55.

Perspiration or Body Odour — What You Need to Know Good personal hygiene is important to prevent body odour:

Bathe or shower using soap or antibacterial skin cleanser daily if possible to prevent build-up of bacteria, sweat and dead skin cells. If daily cleansing is not possible, sponge baths daily will help to control odour. Wear clean clothes that are made from natural fabrics and are breathable to reduce odour.

Apply an antiperspirant to the underarm area each day, even on days you don't have a bath or shower.

To treat feet that are sweaty and/or have an odour:

Wash feet regularly and dry thoroughly to prevent odour as well as fungal infections. Feet may need to be washed each day to control foot odour. Use an absorbent foot powder up to twice daily to help control moisture and odour.

Wear footwear that lets the feet breathe, such as leather shoes or sandals along with cotton or wool socks. Alternate shoes daily to allow a thorough drying in between wearings.

Apply an antiperspirant to the bottoms of the feet if sweating is not controlled with the above measures.

If you have extremely sweaty hands, feet or underarms:

Talk to a pharmacist or doctor about trying a stronger antiperspirant that contains a higher concentration of aluminum chloride than regular antiperspirants. To reduce irritation from antiperspirants that contain aluminum chloride:

thoroughly dry the area before application of the antiperspirant using a towel or blow dryer on low heat. apply stronger antiperspirants at night and wash off first thing in the morning.

once sweating is controlled, reduce the use of the stronger concentration of aluminum chloride to once or twice a week. Use a regular antiperspirant to control odour during the day.

If the product irritates the skin, talk to a pharmacist or doctor for other options.

CPhA assumes no responsibility for or liability in connection with the use of this information. For clinical use only and not intended for for use by patients. Once printed there is no quarantee the information is up-to-date. [Printed on: 03-03-2016 02:17 PM] RxTx, Compendium of Therapeutics for Minor Ailments © Canadian Pharmacists Association, 2016. All rights reserved

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