As reported by the Waterbury Republican-American, August 26, 2004.

Soaking Solution

By Tracey O'Shaughnessy

In the heat of their torrid love affair, Napoleon penned an earnest request to his lover, Josephine. Don't bathe.

In one of Napoleon's most infamous letters to the former Marie-Joséphe-Rose de Tascher, the Corsican general implored her to avoid perfumes or unguents. He wanted to fully inhale her body odor.

We've become a bit more persnickety in our olfactory tastes in the last 200 years. Americans spent a reported $700 million a year on deodorants, antiperspirants, lotions and creams to make us smell nice -- or not at all. All to avoid the ancillary byproduct of a crucial bodily fluid: Sweat.

Sweat, that salty stream of fluid that coats your palms when you're nervous, streams down your temples when you're exercising and, most embarrassingly, down your underarms when you are either, is the body's central cooling system. You're more likely to notice it now, in the dog days of summer, but you are sweating almost all the time and almost everywhere. The only place there are no sweat glands are the genitals.

But increasingly, Americans want to find relief from excess sweating, a condition that is not fatal, but acutely embarrassing. The condition, hyperhidrosis, affects up to 8 million Americans for whom traditional methods offer no relief.

The condition is not necessarily dangerous but can be acutely embarrassing, so much so that the U.S. Food and Drug Administration recently approved Botox to treat excessive underarm sweating.

"To those who criticized this approval in the press as nothing more than a cosmetic indulgence, I suggest they speak to some of my patients who say they are afraid to shake hands or raise their arms and have to change shirts frequently for fear of being embarrassed," said Dr. Ronald L. Moy, a Los Angeles dermatological surgeon. "For them, Botox will eliminate this personal stigma and restore their self-confidence."

Nearly 90 percent of Americans make a point of dabbing on a leading deodorant or antiperspirant at least once a week, according to Mediamark Research Inc. A quarter of all Americans don't want to take any chances, and apply such protection more than once a day.

Botox may offer some relief, but it is expensive, an estimated $500 to $1,000 a treatment, said Dr. Philip Kerr, a dermatologist at the University of Connecticut. Some insurance companies cover the cost, said Dr. Carolyn I. Jacob, a dermatologic surgeon in Chicago. She said she was surprised the FDA approved Botox for the underarms first because sweaty palms can be more of an impediment, particularly in driving.

"I have people who can literally stand there and wring sweat from their hands," she said. "It's terribly embarrassing."

Botox, Botulinim Toxin Type A, works by inhibiting the neurotransmitter acetycholine, the chemical on the sweat gland that stimulates sweat. It is injected 16 or 17 times in each underarm just under the skin and remains effective for six to nine months. "The reason it works is it inhibits acetycholine, the main player in the release of sweat from the eccrine gland," said Jacob.

But Botox is generally not the first line of defense for excessive sweating. Other medicines, notably aluminum chloride hexahydrate, are generally used first.

That topical medicine can be applied to the affected area nightly, said Kerr, but it can cause skin irritation. Still, he said, "It is very effective for a lot of people, particularly under the arms."

The body has about 2 million to 4 million sweat glands, which reside midway through the skin and actually become larger the more we exercise. There are two types of sweat glands, eccrine glands and apocrine glands. Both produce perspiration, a cocktail of water, salt and trace amounts of electrolytes that helps regulate body temperature.

The eccrine glands are relatively benign, producing an odorless salty fluid. The sweat on your palms, for instance, comes from the eccrine glands. By contrast, apocrine glands, which are on your scalp, underarms and genitals, produces sweat that interacts with bacteria and "produce what we would consider today a foul odor," says Kerr.

The contemporary reference is not incidental and may explain Napoleon's feverish attachment to Josephine's odor. "These glands are on us for a reason," Kerr explains. He speculates that the apocrine glands, which are not developed until puberty, emit an odor found to be sexually stimulating. "Now," he says, "our sensibilities have changed and we consider it foul."

Other factors, including foods or drugs, influence how a person's sweat smells. But it is usually not simply the scent, but the amount of sweat that causes those with hyperhidrosis to seek treatment.

"A lot of times people don't realize it's abnormal or that it's a condition that can be treated," said Jacob.

Treatment generally focuses on cutting down on the nerve impulses that causes the sweat glands to kick into action or plug up the sweat ducts to decrease perspiration and water. Aluminum chloride hexahydrate is one of those treatments. But it is less effective for sweaty palms because of the amount of touching a person does in a day. Those patients may decide on an anticholinergic pill, which attacks the nerve endings to the sweat glands, inhibiting sweat. But that pill can cause bladder retention, dry mouth and constipation.

Others patients use iontophoresis, in which they place their hands or underarms in a salt water solution treated with an electrical charge. Patients use a home-operated machine a few times a week to shock the sweat glands to stop producing sweat. Finally, surgical options are available that damage the nerves that produce the sweating in the first place, a last resort for patients.