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Abstract

Hyperhidrosis (HH) manifests as excessive perspiration from different regions of the body, which can be both uncomfortable and humiliating. The aetiologic factors associated with primary HH are inadequately understood. The allopathic approach to treatment includes pharmaceutical or surgical interventions, which have demonstrated efficacy but are generally invasive and associated with multiple adverse effects. This case presentation describes a 40 year-old male suffering from anxiety-related HH who was treated with acupuncture. Following the treatment, the patient experienced a significant improvement in subjectively evaluated levels of stress, anxiety and perspiration. The author concludes that acupuncture may be a safe and effective therapeutic modality to diminish the intensity of primary HH to tolerable levels.
Journal of Chinese Medicine • Number 108 • June 2015 37
Acupunc ture for the Treatmen t of Hyperhidro sis: A Case Repor t
Acupuncture for the
Treatment of Hyperhidrosis:
A Case Report
Introduction
Hyperhidrosis (HH) is profuse perspiration that is
excess to that required for thermoregulation. HH
is identied as general or focal depending on the
distribution of tissues involved. The areas that are
often affected by this condition are those containing
the highest density of eccrine and apoeccrine sweat
glands:1 the scalp, the axilla, the genitalia, the palmar
region of the hands and the plantar surface of the feet.
About 2.8 per cent of the US population is aficted by
this condition, with 1.4 per cent classied as axillary,
0.5 per cent as palmar and the remaining cases as
‘other’.1
There are two main forms of HH: primary and
secondary. In primary HH there is no obvious
causative factor, while secondary HH has been
observed in conjunction with several other factors
such as anxiety, malignancies, central nervous
system abnormalities, endocrine disorders, thoracic
outlet syndrome, reex sympathetic dystrophy,
various dermatological conditions, auriculotemporal
syndrome, Gopalan syndrome and genetic diseases,
and also in conjunction with some medications.1,2,3
Primary HH typically occurs in individuals aged 25
to 64.1 However, it may originate in childhood and
continue throughout life.4 The distribution of cases
among males and females is equal.1
Although the exact aetiology of HH is unknown,
a study conducted by Ro et al. demonstrated that
there is a genetic component to hyperhidrosis.5
An imbalance between activity of the sympathetic
nervous system (SNS), limbic system and anterior
hypothalamus has also been established.7 Therefore,
the fundamental aetiologic factor corresponding to
primary HH is hypothesised to be hyperactivity of
the SNS, which is exacerbated by emotional stress.
The conventional therapeutic approaches for
treatment of HH involve surgery, administration
of pharmaceuticals or Botox (botulinum toxin)
injections. Surgical abstraction can be minimally
invasive and involve the removal of the local eccrine
glands or subcutaneous tissue, or it can be extensively
intrusive, involving the abscission of a sympathetic
ganglion.1 In the latter procedure, the patient is
anaesthetised and a bifurcate endotracheal tube is
inserted between the bronchi of the respiratory tract;
an incision is then created in the intercostal space,
inducing a pneumothorax; the ganglion in the thoracic
cavity at the level associated with hyperhidrosis is
identied, and either thermocoagulation or surgical
excision is performed; the lung is then reinated.8
Both nominally and signicantly invasive surgery can
have side‑effects such as infection, and major surgery
can be extremely stressful on the body, impeding
recovery.
The primary medication for HH is oxybutynin,
which is an anti‑cholinergic agent1 that induces
dry mouth and eyes, constipation and dyspepsia
due to its inhibitory effects on the parasympathetic
nervous system.9 Botox injections, which prevent
perspiration by initiating temporary paralysis of the
neuromuscular junction, can also be harmful, causing
dysphagia, local muscular weakness, generalised loss
of muscular strength, dry mouth, pain encompassing
Abstract
Hyperhidrosis (HH) manifests as excessive perspiration from different regions of the body, which can be both
uncomfortable and humiliating. The aetiologic factors associated with primary HH are inadequately understood.
The allopathic approach to treatment includes pharmaceutical or surgical interventions, which have demonstrated
efficacy but are generally invasive and associated with multiple adverse effects. This case presentation describes a
40 year-old male suffering from anxiety-related HH who was treated with acupuncture. Following the treatment, the
patient experienced a significant improvement in subjectively evaluated levels of stress, anxiety and perspiration.
The author concludes that acupuncture may be a safe and effective therapeutic modality to diminish the intensity of
primary HH to tolerable levels.
By: Brett R. Martin
Keywords:
Hyperhidrosis,
sweating,
acupuncture,
Chinese medicine
Journal of Chinese Medicine • Number 108 • June 2015
44 Acupunc ture for the Treatmen t of Hyperhidro sis: A Case Repor t
the site of the injection, dyspnoea or incontinence.10,11
Conventional medical therapies have been shown to be
effective for the relief of symptoms of HH. However, due
to the adverse effects associated with them, some patients
seek alternative therapies. Acupuncture is marginally
invasive with few side effects and has proved effective for
the treatment of various conditions. Unfortunately there
is very little research demonstrating its effectiveness for
the treatment of HH, although one study administering
acupuncture versus a benzodiazepine demonstrated
that acupuncture treatment was 96.7 per cent effective
compared to 57.7 per cent efcacy in the pharmaceutical
group.12 The purpose of this case report is to describe the
treatment of a male patient with HH that had commenced
during puberty, and to analyse the safety and efcacy
of acupuncture monotherapy as a potential alternative
therapeutic modality. Therefore, no modications were
made to the patient’s diet, no additional supplements were
added or removed and no other treatment was employed.
Case report
Case presentation
A 40‑year‑old male post‑graduate student sought
acupuncture treatment for HH. Both his father and brother
suffered from the same condition, indicating a genetic
component. His HH began during puberty and was
characterised by intense perspiration, heat and oedema
of the palmar and plantar regions. The frequency of his
HH had decreased only minimally as he advanced in age,
although the oedema had subsided.
The patient experienced concurrent anxiety, which
exacerbated his HH. The anxiety had manifested in
adulthood, but had become more pronounced over the
previous six months. The primary manifestation of the
anxiety involved thoughts racing through his mind,
disrupting his ability to concentrate or sleep. Despite
the sleep disruption, however, he felt refreshed upon
waking. He experienced anxiety about 80 per cent of the
time during the day. On a scale of one to ten, he rated his
anxiety as ranging between seven and ten. Other factors
that aggravated his HH were heat, exercise and stress.
The HH interfered with his ability to write and to
perform manual therapy in class. The symptoms of
HH lasted throughout the entire day, yet the amount of
excretion was less severe at home. On a scale of one to
ten, he rated his HH at nine or ten. The patient utilised
iontophoresis as a home treatment, placing his hands
into bowls of water containing rubber pads connected to
electrodes that apply a low intensity electrical stimulation.
He did this for 30 minutes, twice a day, for courses of 12
days and noted that it helped. However, it was very time‑
consuming. He also drank red wine two to three times a
week, which seemed to slightly diminish the symptoms
of HH.
History, exam and lab findings
The patient ingested 1000 mg ginger, 1000 mg turmeric, 400
mg magnesium, 5000 IU vitamin D3 and a multivitamin
daily for general health purposes. He also intermittently
consumed valerian root or Benadryl to aid sleep, but
did not use illicit drugs and had not been prescribed
any medication. He drank a half‑litre bottle of water
two or three times a day and did not consume coffee or
other caffeinated beverages. He generally preferred cold
drinks and usually felt hot. His typical diet consisted of
boiled eggs, pasta, salads, chicken and occasionally red
meat, and he reported experiencing cravings for sweet
foods. He sporadically experienced hypophagia with
no precipitating factor, and this had increased over the
previous six months. The patient experienced two to three
bowel movements a day with well‑formed stools.
A conventional examination revealed no abnormalities.
His vitals, reexes, muscle strength tests, cranial nerves
exam and cardiac auscultation were within normal
parameters. All lab results conducted within the previous
year were unremarkable. His pulse was wiry on both
sides and slightly slippery on the right. His tongue was
pale, quivering and swollen, with teeth marks and a thin
white coat.
Diagnosis and treatment plan
The pattern diagnosis was Kidney yin deciency, leading
to Liver qi stagnation disturbing the shen and overacting
on the Spleen leading to Spleen qi deciency. The treatment
protocol focused on fortifying the Kidney, nourishing
yin, coursing Liver qi, strengthening the Spleen, clearing
heat, calming the shen and regulating the water passages.
See below for a full discussion of the pathophysiology
involved.
Treatment
Acupuncture was performed once a week for a 12‑week
period. The duration of each treatment was 20 minutes.
The acupuncture points selected for treatment were:
Yintang (M‑HN‑3), Baihui DU‑20, auricular Shenmen (R),
auricular Sympathetic (L), auricular Spleen (R), Auricular
Liver (L), Guanyuan REN‑4, Shuifen REN‑9, Zhongwan
REN‑12, Shanzhong REN‑17, Daheng SP‑15, Hegu LI‑4
(L), Taichong LIV‑3 (R), Houxi SI‑3 (L), Wai guan SJ‑5 (L),
Neiguan PC‑6 (R), Shenmen HE‑7 (R), Taiyuan LU‑9 (R),
Zusanli ST‑36 (R), Xiyang GB‑34 (R), Sanyinjiao SP‑6 (L),
Taixi KID‑3 (R), Taibai SP‑3 (L) and Zhaohai KID‑6 (L).
The majority of the yang channel points for clearing heat
were inserted on the left, as it is the yang half of the body.
However, some of the unilateral points were inserted on
one side only based on the patient’s tolerance to needling
and ability to relax. Although not every point was selected
every time, most points were utilised in a majority of
treatments.
The primary points for enhancing the function of the
Journal of Chinese Medicine • Number 108 • June 2015 45
Acupunc ture for the Treatmen t of Hyperhidro sis: A Case Repor t
Kidney and nurturing yin were Taixi KID‑3, the yuan
source point of the Kidney, Guanyuan REN‑4 to reinforce
the Kidney essence and function and nourish Kidney
yin,14 and Zhaohai KID‑6 to calm the spirit.
Additional points used to calm the spirit were Yintang
(M‑HN‑3), auricular Shenmen and Sympathetic, and
points referred to as the ‘Buddha’s triangle’: Neiguan
PC‑6 (a command point for the chest and Pericardium luo‑
connecting point which regulates Heart qi and clears heat),
Shenmen HE‑7 (the yuan source point, which augments
the Heart function, soothing the shen) and Taiyuan LU‑9.
Points used to expel heat were Houxi SI‑3 and Baihui
DU‑20.14
Several points were selected for mitigating exuberant
Liver qi and augmenting its harmonious circulation,
including Hegu LI‑4 with Taichong LIV‑3 (Hegu LI‑4 also
regulates sweating and Taichong LIV‑3, the yuan source
point of the Liver, subdues hyperactive Liver yang and
nourishes Liver yin14), auricular Liver, Shangzhong REN‑
17 and Xiyang GB‑34.
As well as coursing Liver qi, re-establishing the function
of the Spleen was a central aspect of this treatment
strategy. The points used to restore Spleen function were
auricular Spleen, Taibai SP‑3, Daheng SP‑15, Sanyinjiao
SP‑6, Zusanli ST‑36 and Zhongwan REN‑12. The latter
two points exhibit the potential to inuence water
passages throughout the body and were therefore apt for
this condition. The luo‑connecting point of the San Jiao,
Waiguan SJ‑5, which is responsible for the coordination
of water transportation, assists with perspiration, and
additionally clears heat, was also included.15 Shuifen REN‑
9, the name of which translates as ‘Water Separation’ was
also utilised for the modulation of the water passages.14
Results
From the baseline to the end of the treatment period, there
was a 20 per cent reduction in perceived stress, a 30 per
cent decline in perceived anxiety, a 50 per cent decrease in
the amount of time spent feeling anxious and a 40 per cent
reduction in level of hyperhidrosis (based upon the level
of saturation of the patient’s paper during class).
Date Perceived Stress Level
(Scale 1‑10)
Perceive d Anxie ty Level
(Scale 1‑10)
Percent age of Time Anxio us (Scale
1‑100%)
Hyperhidrosis Level (Scale
1‑10 )
19/09/14 7 7 80% 9
26/0 9/14 7 4 50% 6
03/10/14 7.5 570% 5
10/10/14 7 7 70% 8
17/10/14 7 6 50% 7
24/10/14 86.5 75% 8
31/10/14 5 5 45% 5
07/11/14 5 4 40% 5
12/11/14 4 3 30% 4
21/11/14 4 3 30% 3
25/11/14 4 4 30% 3
03/12/14 5 4 30% 5
Table 1: Levels of perceived stress, anxiety and hyperhidrosis during treatment period
Graph 1: Perceived stress, anxiety and
hyperhidrosis during treatment period
19/9/2014
26/9/2014
10/3/2014
10/10/2014
17/10/2014
24/10/2014
31/10/2014
7/11/ 2 014
12/11/ 20 14
21/11/2014
25/11/2014
3/12/ 20 14
Journal of Chinese Medicine • Number 108 • June 2015
46 Acupunc ture for the Treatmen t of Hyperhidro sis: A Case Repor t
Date Perceived Stress Level
(Scale 1-10)
Perceived Anxie ty Level
(Scale 1-10)
% of time Anxious (Scale
1-10 0%)
Hyperhidrosis Level (Scale
1-10)
16/12/14 6 4 30% 4
26/12/14 2 1 10% 1
03/0 1/15 1 1 10% 1
14/0 1/15 3 6 60% 6.5
20/01/15 3 5 50% 5
Table 2: Follow-up period levels of perceived stress, anxiety and hyperhidrosis
Graph 2: Perceived
percentage of time
experiencing anxiety
19/9/2 014
26/9/2014
10/3/2 014
10/10/2014
17/1 0/ 20 14
24/10/ 2014
31/10/2014
7/11/ 2 014
12/11/20 14
21/11/2014
25/ 11/2014
3/12/ 2014
Graph 3: Follow-up representation
of perceived stress, anxiety and
hyperhidrosis
16/12 /20 14 26/ 12/2 014 3/1/2 015 14/1/2 015 20/1/2015
Discussion
In determining the diagnosis for this patient, numerous
aetiological factors were considered. The rst aspect of
this case was the genetic heritability of HH, indicating
that the pre‑heaven essence of the Kidney was involved.
This was considered particularly relevant as the patient’s
condition began during puberty, which is a crucial phase
of development controlled by the Kidney.15 Since his
HH began during this time and was unaccompanied
by any other ailment or disorder, it was postulated that
the Kidney was the primary organ responsible for the
commencement of the condition. Kidney yin deciency
was apparent from the ‘ve centre heat’ symptoms, in
which the yin areas of the palms and soles manifested
heat and oedema, and the fact that heat aggravated his
condition. The excessive perspiration seems to have been
a compensatory mechanism of the body attempting to
cool these areas.
A central aspect of the treatment of this patient was
subduing hyperactivity of Liver qi and enhancing the
Liver function of circulating qi. The patient was a student
in a doctorate level programme. He had multiple exams
and paper assignments to complete and his workload
was high, causing him to experience severe stress. It was
hypothesised that this stress was inducing stagnation of
Liver qi and hyperactivity of Liver yang, which was rising
to disrupt the function of the shen. As the shen houses
the mind, this resulted in intense anxiety that manifested
most of the time.
As a result of hyperactivity of the Liver qi, the Liver
was overacting on the Spleen, causing deciency that
manifested as hypophagia and cravings for sweets.
Furthermore, the pathological emotion of the Spleen is
worry, which was exacerbating the patient’s pre‑existing
Journal of Chinese Medicine • Number 108 • June 2015 47
Acupunc ture for the Treatmen t of Hyperhidro sis: A Case Repor t
anxiety. Several studies have also demonstrated a
correlation between hypophagia and anxiety.13
An important consideration for this case was that the
effect of acupuncture as a monotherapy was the primary
outcome being measured. Therefore, although the turmeric
and ginger being ingested by the patient were acrid and
warm agents that may have been exacerbating the pattern
of yin deciency, the dosage of these was not altered. If the
safety and efcacy of acupuncture were not the primary
outcomes being measured, other modalities would have
been employed to treat the patient such as cooling and
calming herbs to supplement yin, whilst advising the
patient to avoid such warm and acrid medicinals. It is
notable that the patient still saw signicant improvement
despite not excluding the ginger and turmeric.
The therapeutic approach for HH in this case was found
to be effective. However, the treatment did not completely
resolve the anxiety and HH. An important consideration
in this regard is that even with surgery, HH is rarely
completely resolved. Studies indicate that patients who
elect to receive surgical abstraction or removal of local
glands and tissue experience a 60 to 65 per cent reduction
in HH.16,17 In a three‑year follow‑up study of treatment by
thoracoscopic sympatheticotomy it was noted that 88.7
per cent of patients were satised with the surgery, yet
77.5 per cent of these patients still experienced sweating
after their operation.18 Another study utilising thoracic
sympathectomy demonstrated that 71.6 per cent of
patients still experienced HH to some degree.19 However,
a study performed in 2007 documented that 41 per cent of
the participants reported a moderate to severe reduction
in their quality of life after surgery.20
Other therapeutic methods such as drug therapy or
Botox have not been demonstrated to be completely
effective either. Oxybutynin was noted to improve
symptoms in 80 per cent of patients, but all of those
patients suffered from side effects.21 The intensity of the
adverse effects produced was severe and resulted in the
discontinuity of treatment in 25 per cent of the patients.21
Although a plethora of negative effects are associated with
Botox injections, it has a high rate of efcacy, reducing the
intensity of the symptoms by as much as 72.1 per cent for
four months with palmar HH and 12 months with axillary
HH.22,23 Consequently, HH patients would have to receive
these injections every four months (for palmar HH) or
12 months (for axillary HH) to sustain their effects, and
long‑term utilisation of Botox has been shown to induce
local muscle atrophy.24 Therefore, since the other main
treatment methods employed for primary HH have been
shown only to reduce symptoms rather than resolve them
entirely, the improvement seen in this case is comparable
to that achieved by other methods. Although complete
remission of symptoms was not observed, each treatment
parameter that was evaluated showed a sustained
improvement. Additionally, it is important to note that the
patient involved in this study was subject to a considerable
amount of stress over a prolonged period of time.
Upon examination of the data, the greatest efcacy was
revealed in the amount of time that the patient experienced
anxiety and the level of HH, which declined from 80 to 30
per cent and nine to ve respectively. Lesser reductions
were discovered with stress (seven to ve) and anxiety
(seven to four). At the beginning of the study, the patient
was anxious 80 per cent of the time, which was disrupting
his sleep. However, after the rst appointment, a signicant
drop in the level and incidence of anxiety occurred, from
seven to four and 80 per cent to 50 per cent respectively.
In addition, he experienced a drastic improvement in his
sleep and did not report any further problems with his
appetite throughout the entire treatment period. These
symptomatological improvements indicated that the
hyperactivity of the Liver and weakness of the Spleen
were being alleviated.
It should be noted that the beginning of the follow‑up
period (December 16th) was midway through the patient’s
nal exams. The fact that despite the patient’s stress
level being high his anxiety and HH remained low was
particularly signicant. He also noted that he experienced
episodes when his HH became non‑existent for several
hours, and after the new trimester commenced, six weeks
after his nal acupuncture session, the severity of his
anxiety and HH remained below the original values.
Limitations
The greatest drawback of this study was that an instrument
was not used to assess the intensity of the patient’s HH.
The intensity of the HH was based solely on the patient’s
perception and the degree to which his paper became
saturated while writing during classes. Another limitation
was that appointments did not follow a sequential
pattern – after the eighth week of treatment there were
a variable number of days between treatments. This
was unavoidable due to practitioner‑patient availability.
A further disadvantage of this study was the limited
contact during the follow‑up period, which fell during the
holidays. Lastly, the effects of long‑term therapy were not
established.
Conclusion
There are a wide variety of treatment options available for
the management of primary HH. However, many of the
options are costly, have side‑effects and cannot guarantee
resolution of symptoms. In this retrospective study,
acupuncture was able to drastically reduce the subjective
intensity of the anxiety, the duration of the anxiety and
the severity of the HH in a student enrolled in an arduous
post‑graduate programme. It is therefore the conclusion
of the author that acupuncture may be a safe and effective
Journal of Chinese Medicine • Number 108 • June 2015
48 Acupunc ture for the Treatmen t of Hyperhidro sis: A Case Repor t
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alternative for the management of primary HH and
associated anxiety. However, additional studies must be
performed to conrm this conclusion.
Brett Martin, DC, MsAc, is a chiropractor and acupuncturist. He has
clinical experience working in drug and alcohol rehabilitation, a family
chiropractic practice, a post-traumatic stress disorder clinic, a cancer
resource centre and a hospital pain management department. He
teaches anatomy and physiology, biochemistry, medical genomics and
botanical medicine at National University in Florida. He can be
contacted at bmartin@nuhs.edu.
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Objective: Endoscopic thoracic sympathectomy or sympathicotomy, for the treatment of palmar, axillary, and plantar hyperhidrosis, is generally performed at one or two levels, between T2 and T5. Compensatory sweating (CS) is a severe and undesirable side effect of this procedure. Here, we describe the success of treatment and degree of postoperative CS in sympathicotomy patients. Subjects and methods: This study included 80 patients treated by uniportal (5-mm) thoracoscopic sympathicotomy (electrocautery) for primary hyperhidrosis over a 6-year period (2007-2013). Sympathicotomy was performed bilaterally at T2 for blushing (n=2), T2-T3 for palmar-only hyperhidrosis (n=34), T2-T4 for palmar and axillary hyperhidrosis (n=39), and T3-T4 for axillary-only hyperhidrosis (n=5). Outcome was assessed 2 weeks postsurgery at the clinic and annually thereafter by telephone questionnaire. Mean follow-up time was 35.2±23.3 months. Questionnaires assessed patients' degree of sweating, postoperative CS, overall satisfaction, and complications. Results: Seventy-one patients (88.7%) were very satisfied, whereas only 9 (11.3%) were dissatisfied with the procedure. Complication incidence was 7.5%, and CS occurred in 77.5% of patients. Therapeutic success rate was 97.5%; complete relief of hyperhidrosis was achieved in 72 (90%) patients, whereas 8 (10%) experienced recurrence. Conclusions: CS is a frequent side effect of thoracoscopic sympathicotomy. We recommend all patients undergoing this procedure should be warned of the potential risk of developing severe CS.
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OBJECTIVES: Primary hyperhidrosis usually affects the hands, armpits, feet and cranio-facial region. Sweating in other areas is common in secondary hyperhidrosis (after surgery or in specific clinical conditions). Oxybutynin has provided good results and is an alternative for treating hyperhidrosis at common sites. Our aim was to evaluate the efficacy of oxybutynin as a treatment for primary sweating at uncommon sites (e.g., the back and groin). METHODS: This retrospective study analyzed 20 patients (10 females) who received oxybutynin for primary focal hyperhidrosis at uncommon sites. The subjects were evaluated to determine quality of life before beginning oxybutynin and six weeks afterward and they were assigned grades (on a scale from 0 to 10) to measure their improvement at each site of excessive sweating after six weeks and at the last consult. RESULTS: The median follow-up time with oxybutynin was 385 days (133-1526 days). The most common sites were the back (n = 7) and groin (n = 5). After six weeks, the quality of life improved in 85% of the subjects. Dry mouth was very common and was reported by 16 patients, 12 of whom reported moderate/severe dry mouth. Five patients stopped treatment (two: unbearable dry mouth, two: excessive somnolence and one: palpitations). At the last visit, 80% of patients presented with moderate/great improvement at the main sites of sweating. CONCLUSION: After six weeks, more than 80% of the patients presented with improvements in their overall quality of life and at the most important site of sweating. Side effects were common (80% reported at least one side effect) and caused 25% of the patients to discontinue treatment. Oxybutynin is effective for treating bothersome hyperhidrosis, even at atypical locations and most patients cope well with the side effects.
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[Purpose] The purpose of this study was to evaluate the efficacy of tap water (drinking water) and normal saline (sodium chloride solution 0.9%) iontophoresis treatment for a patient with idiopathic hyperhidrosis [Subjects and Methods] In this study, tap water and normal saline iontophoresis were used to treat a 21 year-old female who was suffering from severe palmoplantar idiopathic hyperhidrosis. Post-iontophoresis sweat intensity of 8 treatment sessions were averaged and then normalized relative to the corresponding mean value which was obtained before iontophoresis treatment. [Results] The subject showed 24.72% and 42.01% decreases in sweat intensity following tap water and normal saline iontophoresis, respectively. [Conclusion] Tap water and normal saline iontophoresis are effective in the treatment of idiopathic hyperhidrosis. However, normal saline iontophoresis is 1.7 times more effective than tapwater iontophoresis at obstructing secretion.
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