Dee Anna Glaser, MD: Let’s discuss topicals. How do you start with some of the topicals in your patients?
Adelaide Hebert, MD: Well, I like to ask how the patient is using them, if they have tried them before. I will make sure that if they are using, let’s say, a clinical strength deodorant in the armpit area, they should be putting that on twice a day—which is often not what they understand, or they don’t read the label, or they just forget to do it. They’ll get a much better outcome if they’re able to do that. If they’re using a product like aluminum chloride, they really have to put that on dry skin so that the skin doesn’t get irritated from the hydrochloric acid that is formed. That will irritate the skin if the medication is applied to a moist surface, so we need to educate the patient on how to use it properly. Topicals can be very effective. We’re actually really excited to see that we’re going to have more therapies in the topical realm, which will expand our ability to help so many patients. We may not have to use a systemic medicine, which some patients are a little bit loath to do.
Dee Anna Glaser, MD: So many patients are told to occlude their aluminum chloride. Is that something that you suggest or don’t suggest?
Adelaide Hebert, MD: I generally don’t suggest it, although that was the way I was initially taught. I’ve learned that this increases the irritation. If applying to dry skin, many patients can do quite well with that. Many of the patients I have—and I know the same is true for the ones who you see—are so severe in their hyperhidrosis that they really need additional therapy. But when that can work early on, it can be a really wonderful means for the patient to control a troublesome condition.
Dee Anna Glaser, MD: Do you find that your patients are coming in having tried some products from the Internet or some different aluminum chloride products or other things?
Adam Friedman, MD, FAAD: Oh, absolutely. This is the era of do-it-yourself. And, of course, it should be natural, as well. First and foremost, as was mentioned, it’s how you use it. I think there’s also a big misconception. A lot of people think deodorants and antiperspirants are the same thing. A patient may be putting on a deodorant 3 times a day, which is not going to do anything for sweating. Now they’re creating a dermatitis because of some antimicrobial or some fragrance material that has nothing to do with blocking sweat. That’s really the way to talk about. An antiperspirant’s purpose is to occlude the openings, to kind of form a plug with elements of the sweat. I really lean more toward the aluminum chloride formulation because there’s a decrease of risk for irritation from that hydrochloric acid.
I tell them, “If you put on your aluminum chloride formulation when you’re sweating, you form some hydrochloric acid.” Their eyes bulge. “What? What am I putting on my skin?” So, that really gets them on board for using it at the right time, which is at night. They can use a deodorant in the morning or a deodorant/antiperspirant in the morning, but they’ve got to do the antiperspirant at night because that’s when they are not sweating. That’s when you get the greatest chance to occlude those pores, to prevent that sweating.
Dee Anna Glaser, MD: I have patients who may use the aluminum chloride prescription maybe 3 nights a week. And then, on the other nights, they may use an over-the-counter clinical strength, and then use the clinical strength in the morning. So, it’s really about trying to find that regimen that works best for them and their skin type. We sort of focused on the axilla, but these products can be applied to nonaxillary sites—hands, feet, as you mentioned, and under the breast or any of the areas that are affected by hyperhidrosis.