A COMPARISON OF TOPICAL TANNIC ACID VERSUS IONTOPHORESIS IN THE MEDICAL TREATMENT OF PALMAR HYPERHIDROSIS CLGoh, K Yoyong ABSTRACT This is a report comparing the efficacy of tannic acid lotion (an astringent) and iontophoresis in the medical treatment of idiopathic hyperhidrosis. Ten patients with long-standing symptomatic idiopathic palmar hyperhidrosis were recruited into the study. One palm was treated with daily tannic acid (20%) lotion and the opposite palm with iontophoresis. Visual scoring using a visual analog ‘sale by patients and assessors showed the mean score to be significantly lower on the iontophoresis treated patm than the tannic ‘acid treated palm. There was significant reduction inthe severity of hyperhidrosis on the iontophoresis treated palm after treatnient, There was also a significant reduction in transepidermal water vapour loss on the iontophoresis treated palms. The study indicated that iontophoresis isan effective medical treatment for idiopathic hyperhidrosis. The disadvantage of iontophoresis is its short-lived affect. Patients need 10 undergo the treatment weekly to achieve euhidrosis. Keywords: astringent, sweaty palm, transepidermal water loss, tannic acid, iontophoresis SINGAPORE MED J 1996; Vol 37: 466-468 INTRODUCTION equipment (Ionos 7, Nemectron GmbH, W Germany). Palmo-plantar hyperhidrosis is a common skin disorder __Glycopyttonium bromide 1% solution was used as iontophoretic ‘encountered inthe skin clinic. Most cases of hyperhidrosis are -—-mediumn. The principle of treatment has been described ‘idiopathic. The commonest medical treatment include topical _elsewhere' ntiperspirants™ and iontophoresis®*. “The severity of hyperhidrosis of each palm was assessed In previous reports, response to hyperhidrosis is based on subjectively using a visual analog seale (0 = total dryness and subjective and qualitative assessment, Tannic scid,anastingent, 10 = very wet) by the patients and one ofthe authors at weekly has been used for the treatment of hyperhidrosis. However, interval just before the patient begins his weekly iontophoresis. there is no report to prove its effieacy in controlling palmar treatment hyperhidrosis, In this study we compare the efficacy of topical “Transepidermal water vapour loss (TEWL) measurement was tannic acid lotion with that of iontophoresis in the treatment of carried out with evaporimeter (EPI Evaporimeter, Servomed, idiopathic palmar hyperhidrosis using visual scoring and Valingby, Sweden). The rate of skin water vapour loss (expressed “objectively by measuring transepidermal water loss with an _in grams of water/square metre per hout). The principle of the ‘evaporimetr, cevaporimeter measurement has been described elsewhere”. "The patient rested in an air-conditioned room for 5 minutes MATERIALS AND METHOD before TEWL measurement is carried out. The palms were then Ten patients with symptomatic idiopathic palmar hyperhidrosis _dabbed dry with tissue paper. TEWL measurements were carried who have not received any treatment for their hyperhidrosis for out on 5 areas of each palm viz, the skin overlying the 2nd ore than 2 weeks were recruited into the study. Each patient metacarpo-phalangeal joint, Sth metacarpo-phalangeal joints, ‘vas instructed to apply topical tannic acid 20% aqueous lotion _mid-thenar, mi¢-hypothenar eminences and the centre of the ‘on one palmevery night. The ther palm was treated with weekly _ palm. The mean TEWL. for each palm was obtained by averaging, iontophoresis, The decision as to which palm was io be weated the 5 values. Measurement of TEWL foreach palm was obtained ‘with tannic acid was left to the patient. The assessor Scoring _by averaging the 5 values. Measurements of TEWL was carried severity and measuring the transepidermal water loss was"blind” out in the same room to ensure consistency of environmental to this until the end ofthe study condition. The temperature and relative humility of the room ‘was recorded during each follow-up. Procedure/Assessment ‘Treatment was stopped after 4 weeks but visual scoring and ‘The patients were given the topical tannic acid lotion before he TEWL measurement continued fora further 2 weeks. study and instructed to apply it on one palm every night before ‘Comparison was made between the mean visual score and retiring to bed. Patients Were also instructed to atend the clinic mean TEWLoftanic acid Jotion treated palms and iontophoresis, weekly for iontophoresis treatment on the other palm. treated palms. lomophoresis was carried out using our standard iontophoretic Statistical analysis was carried out using non-parametric ‘Signed test (or visual analog scoring) and the paired Student t test (For the uansepidermal water loss measurement), p values National Skin Centre 1 Mandalay Road ‘of less than 0.05 were considered statistically significant Singapore 308205 CLGob, PAMS, MD, RESULTS eae ‘hemcansgcfth 10 pits was 227 years ange 1-35 year) The mean drain of heir symptomatic paar ng MD Topi) ems Gnge 830 yeu) Temes om : ; CCopeate ms 25°C (6D2.5) ad anv humty Corrapntns Pot CL Goh fearsome ant715¢ 466‘Tables I, and ILI show the visual scores and TEWL changes during the stady petiod, There was no significant reduction in visual scores (patient and author assessed) and TEWL changes ‘onthe palms treated with tannic acid lotion. There was significant reduction inthe mean visual scores and TEWL measurement on the palms treated with iontophoresis after the third week. There .was also significant differences in the mean visual scores and TEWL changes between tannic acid treated palms and ‘iontophoresis treated palms after the thd week of treatment ‘The findings also showed that the visual scores and TEWL values began to increase 1 week after stopping iontophoresis, treatment. ‘None ofthe patients experienced any significant side effects from tannic acid lion treatment or iontophoresis, ‘Table I~ Mean severity score of hyperhidrosis (visual analog seale 0-10 cm) as assessed by patients. Comparing tannic acid treated and iontophoresis treated palms, ‘Week tannic acid iontophoresis p-values 0 68 67 032 1 34 49 007 2 35 45 0.03 3 35 45 0.02 4 57 48 001 5 55 43 0.02 6 58. 52 02 Table II Mean severity seore of hyperhidrosis (visual analog scale 0-10 em) as assessed by assessors. Comparing tannic acid treated and iontophoresis treated palms. Week tannieacid ioniophoresis _p values 0 55 56 065 1 62 52 0.08 2 54 47 0.06 3 51 49 0.03 4 31 38 0.03 5 45 26 0.01 6 42 40 0.05 ‘Table IIT - Mean transepidermal water vapour loss (TEWL) values comparing tannic acid treated iontophoresis treated palms ‘Week tannic acid tontophoresis p-values 0 528120) 521( 85) 083. 1 6081163) 546121) 001 2 3631130) 507047) a 3 661145) 5740125) 0.12 4 5800182) 4560134) 0.03 5 484016 39.7045) 002 6 52505) 5300188) O81 THEWL measured in gf water at (C)Standad dvaioe DISCUSSION lontophoresis has been used for the treatment of palmar and plantar hyperhidrosis for many years, Most reports indicated that iontophoresis offered transient eubidrosis of the palms varying from few days to few weeks", With the evaporimes 467 able 10 measure objectively the rate of sweating (degree of hyperhidrosis) during treatment. Our findings confirmed the effectiveness of iontophoresis in the treatment of palmar hyperhidrosis. However, the response to treatment is delayed and transient. Symptomatic hyperhidrosis returned 1 week after stopping treatment. Tannic acid lotion (20%) did not appear to exert any effects on palmar hyperhidrosis. ‘Our patients appeared o observe more significant subjective response to iontophoresis treatment than the objective ‘measurement with TEWL. This could be because patients tend to assess their response through the week whereas our TEWL ‘measurement is conducted only 1 week after iontophoresis treatment, the effect of iontophoresis has probably worn off. Nevertheless, significant reduction in TEWL values were noted after 3 weeks of iontophoresis treatment whereas the palm thet was treated with tannic acid did not show any significant reduction. It would also appear that iontophoresis treatment has | cumulative effect on controlling hypethidrosis. Besides iontophoresis, antiperspirants eg aluminium chloride hhexahydrate has been found to he effective against palmer hyperhidrosis"*". However, reports indicated that response to such treatment is even more shor-lived®. Patients have to apply the antiperspirant daily to achieve any effect. In addition, such antiperspirant tends to cause skin irritation and may be ‘unacceptable tothe patents”. ‘The mode of action of iontophoresis is unknown. Studies have indicated that it does not act by causing the obstruction of| the sweat duct, There was no anatomical changes in the sweat duct before and after iontophoresis". The disadvantage of Jontophoresis is the inconvenience to patients who eed to travel to the clinic regularly for treatment. Miniaturized hand-held ‘ontophoretic equipment are now available for patients to receive home treatment. Several reports have indicated their effectiveness *, Cervical sympathectomy has appeared to be the only way to stop palmar hyperhidrosis permanently. The introduction of endoscopic minimally invasive cervical sympathectomy is reported fo cause less morbidity and complications. I is more ‘widely carried out nowadays", Complications include flushes and dryness onthe palms, forearms and arms. Patients may also ‘experience compensatory hyperhidrosis on other parts ofthe body following sympathectomy. Dermatologists should consider the ‘ros and cons.of cervical sympathectomy before recommending surgery for such a benign skin disorder. It should only be considered afer patients have failed medical control Rurmevers 4. Shelly WB, Huey 1, Satis on topical aniprsprant contol of sullaryhypethidioss. Acta Dorm Venereol (Stockh) 1975; 55; 241 0. 2. GohCL. Aluminium chloride hexahydrate vs palmar hypeshidosis, Evaporimeter assessment. nt J Dermal 1990; 2: 368-70, 3. Bouman HD, Grunewald LEM, The treatment of hyperhidrosis of ‘et with constant current. Am Phys Med 1952; 31: 158-69, 4. Abell E, Morgan K. The treatment of idiopathic hyperhidrosis by ‘lyeorsroniam bromide nd tap water iontophoresis Br} Dermatol 19a 918791 5. Polano MK, cd, Topical skin therapeutics Edinburgh: Churchill Livingstone, 1991: 34 6 Nilsson GE. Messurementf wate exchange through the skin. Med Biol Eng Compot 1975 15: 209-18 7. van Der Valk PGM, Nater JP, Bluemink E. Skin initaney of ‘Surfactant ae assessed by water vapour loss ricasurement} Invest Dematl 1984; 82: 291-3 8. MidtgnardKTI. Anew device fr the reatment of hyperhidrosis by Soncephoress, Br J Denmatl 1986; 14: 485-8,Stolman LP. Treatment of excess sweating of the palms by iomaphoress. rch Dermatol 1987; 123: 893-6, ‘Akins DL, Mesonbeimer J, Debson RTI Etficacy ofthe Drie ‘ui in dhe teatment of hyperhidrosis. Arm Acad Dermatol 1987 16: 828-32 gant ML, Fuchs G. Tapwter iontophoresis in the treatment of hyperhidrosis. Use ofthe Drionic device. lt J Dermatol 1987; 26; 1947 Dah JC, Glent Madsen, Treatment of hyperhidrosis manaum by {ap water iontophoresis, eta Derm Venereol 1989; 69: 346-8, Brandrap F, Laren FO. Axil hyperhidrosis: local eaten with lamin chloride hexahydrate2%in absolut etnanolamine. Acta Dern Venereol (Stockh) 197% 85: 461-5 flat rates, floating rates, Only DBS Finance offers you a choice of 468 M4 1s, 6. Hill AC, Baker GF, Janseng GT. Mechanism of action of iomtophoresis inthe eatment of palmar hyperbiross. Cais 1981; 28: 69-70, Gothherg G, DeottC, Claes G. Thoroseopic sympathectomy for hyperhidrosis - surgical technique, complications and sie eet, Bur) Surg (Suppl) 1994; 572: 51-3, ‘Nicholson ML, Dennis Mi, Hopkinson BR, Endoscopic rashoracc sympathectomy -siccessfl in hyperhidrosis bata the indications ‘beentended? Ann R Coll Surg. 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