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10.1 The structure of the skin
10.2 Functions of the skin
10.3 Introduction to disorders and disease
10.5 Acne vulgaris
10.6 Mycosis fungoides
10.7 Polymorphic light eruption (PLE)
10.9 Pityriasis rosea
10.1 The structure of the skin
This is the superficial part of the skin. It consists of five layers which are:
1. Stratum germinativum – growing layer.
2. Stratum spinosum – layer with bridges.
3. Stratum granulosum – cells and nuclei disintegrating.
4. Stratum lucidum – clear cells.
5. Stratum corneum – keratin flakes.
The keratin flakes are constantly rubbed off and replaced from cells below.
Melanin is a pigment produced by melanocytes which are present in the stratum germinativum.
This is thicker and deep to the epidermis.
It consists of fibrous tissue and contains blood capillaries, sweat glands, sebaceous glands, hair follicles and nerve ending.
10.2 Functions of the skin
The functions of the skin are:
1. Protection – The skin prevents water, bacteria and harmful objects from entering the body.
2. Absorption – substances applied to the skin are absorbed.
3. Temperature regulation – To lose heat, the sweat glands produce sweat which evaporates from the surface and the blood vessels dilate. To conserve heat, the blood vessels contract and the arrector pili muscles produce ’goose pimples’.
4. Fluid and electrolyte balance – Water, sodium chloride and urea are lost in sweat. The skin also prevents excess loss of body fluid, thereby contributing to homoeostasis.
5. Sensory – Nerve endings provide information on the environment, body position, impending damage (by pain, thermal and pressure receptors) and constitute an essential component of the body’s defence mechanism.
6. Self concept – The skin is very important psychologically. Appearance is important to self-image and therefore self-confidence. It identifies us as who we are and to some extent where we belong (family likeness, race and culture). The facial skin particularly expresses state of health and contributes to non-verbal communication, as does hand skin. Destruction, disease or disment involving skin causes severe difficulties for the patient and for the people he cr she meets in society.
10.3 Introduction to disorders and diseases
The patient with skin disease needs a great deal of sympathy and support from the physiotherapist. Unsightly skin lesions do not attract sympathy and support from the public; indeed there tends to be rejection or revulsion of psoriatic patients, and acne can be the subject of very hurtful taunting. People stare a bad skin and children can be heard to say ’Why has that lady got spots, Mummy?’ A 5 year old with psoriasis on her palms and soles cannot find a partner at school – no one wants to hold her hand because ’it feels horrid’. When a young woman’s psoriasis breaks out her husband moves into the spare room and she has to be treated immediately in the physiotherapy department. The distress suffered by these patients is equal to the disability of arthritis or paralysis but is not often seen as such.
Conditions treated by physiotherapy
By ultraviolet radiation (UVR):
2. Acne vulgaris.
3. Mycosis fungoides.
4. Polymorphic light eruption.
6. Pityriasis rosea.
By iontophoresis: hyperhidrosis.
Examination of patients with skin conditions
The history is taken before the patient undresses. Questions asked are:
1. Duration of lesions.
2. Recurring – intervals.
3. Severity – variable.
(c) Effects of these.
5. General health.
6. Occupation, hobbies, lifestyle.
7. Family history of skin diseases.
8. Patient’s views/expectations/previous treatment by physiotherapy.
9. Skin reaction to UVR.
10. Skin type.
11. Rule out contraindications.
1. Chart lesions on body chart.
2. Use different colours or numbers for large patches.
3. Show these to the patient so that both patient and physiotherapist can recognize progress or regression.
If appropriate, note swelling, heat, skin texture. Psoriatic lesions are proud of the skin at first and flatten on first signs of improvement.
1. All ointment, make-up and perfume should be removed.
2. Alcohol should be avoided as it can alter skin sensitivity.
3. A skin test with UVR is appropriate if the Theraktin or mercury vapour air-cooled burner are used.
This is essential for safety and repetition of treatment. The following records should be kept:
1. Distance of patient from UVR source.
2. Time given.
3. Screening if any.
4. Joules per cm2 of body surface (for PUVA treatment).
5. Reaction obtained.
6. Patient’s reports, e.g. itching/burning.
7. Equipment used (the same source of UVR should be used at each attendance).
These are electromagnetic rays with a wavelength between 400 and 100 nm. Conventionally they are divided into three bands:
1. Long, UVA (320-400nm).
2. Medium, UVB (290-320nm).
3. Short, UVC (180-290nm).
UVA: fluorescent tubes in a special cabinet.
UVB: Theraktin – fluorescent tubes. High-pressure ultraviolet mercury vapour burner (HP UV burner), air cooled.
UVC: HP UV burner, air cooled; and water cooled (Kromayer).
Dosage with UVR
Reaction to UVR depends on:
1. Skin type.
2. Skin distance from source (shorter distance, greater reaction).
3. Time of exposure.
4. Age of source – output diminishes with use.
Recording of individual treatment is therefore essential together with reaction obtained if any. Times/dosages suggested in the text must be taken as a guide only.
Minimal erythema dose (MED) is the time taken at a set distance to produce a faint pinking of average skin which fades in a few hours. MED is related to the equipment used. A first-degree erythema (El) is a reaction of a patient’s skin where there is faint pinking which fades within 24 hours of exposure. MED and El are essentially the same thing. A suberythema dose does not produce pinking of the skin except on prominent parts (e.g. buttocks), and this fades in a few hours.
An E2 is a deep pink clearly defined area, which lasts for 2-3 days and is followed by mild peeling.
An E3 is a red, clearly defined area which may be slightly oedematous. It lasts for 5-7 days and is followed by free peeling.
Mode of action of UVR
UVR stimulates synthesis of epithelial cells in the stratum germinativum of the epidermis. In acne this is desirable. An E2 produces accelerated growth of the skin through to the keratin layer, which peels off and clears acne. In PUVA the UVA activates psoralen, which slows down the rate of growth of skin which is desirable in psoriasis. The use of UVR from the Theraktin for psoriasis is an apparent contradiction because it stimulates growth where the problem is that of accelerated growth. Patients undoubtedly get better with UVR given at suberythema dosages, and although this cannot be explained at present this is no reason for denying patients Theraktin treatment where no UVA equipment is available.
This is one of the commonest and most intractable disorders of the skin.
Psoriasis is a chronic inflammatory disease of the skin characterized by clearly definded dry, rounded red patches with silvery scales on the surface.
1. Common age of first occurrence is 15-30 years.
2. Can occur as young as 2 years.
3. Can start as late as 80 years.
*** – Both ***es are equally affected.
Climate – The condition is worse in damp, cold climates. It has been known to clear if a patient who ”suffers quite badly in the UK goes to a sunny climate.
A number of factors appear to predispose or precipitate an exacerbation of the condition. These are as follows:
1. Heredity. There is an inherited defect in the skin which results in psoriasis developing in certain circumstances; 30% of patients have blood relatives with the condition.
2. Infection. Psoriasis has been known to develop after, for example, an upper respiratory tract infection.
3. Trauma – Lesions tend to develop at sites of potential or actual trauma, e.g. mechanical friction, cuts, stings.
4. Anxiety. Psoriasis often appears in relation to mental stress, e.g. bereavement, exams.
5. Drugs – Some drugs, e.g. chloroquine, may precipitate the condition.
6. Diabetes – Some patients with diabetes develop this condition.
The membrane of the skin cells in patients who develop psoriasis contain abnormal proteins which manifest as abnormal surface antigens. Antibodies form in response to these ’foreign’ bodies and are carried by B-lymphocyte cells. When these antibodies lock onto the antigens, a complex reaction takes place at the dermo-epidermal junction and psoriatic lesions are produced.
In normal skin the maturing of epidermal cells takes 21-29 days. In psoriasis this is accelerated to 4 days. What causes the abnormal protein to form and what triggers the antibody-antigen reaction is not known but it is probably related to the predisposing factors already listed.
1. There is increased reproduction in the stratum germinativum.
2. The stratum spinosum is thicker due to an increased number of cells plus oedema.
3. The stratum granulosum is absent.
4. The strata lucidum and corneum are replaced by several layers of nucleated, incompletely keratinized, soft cells (para-keratotic cells).
There is no time for the normal changes to take place through the skin layers. The cells at the surface are sticky and do not fall off like normal keratin. Accumulation of these cells forms scales which over 2-3 weeks dry out and fall off in big flakes.
1. Capillaries are dilated with increased blood flow.
2. Papillae are elongated.
3. There are changes of inflammation.
The centre of the patch heals first causing circular lesions. Normal skin recovery takes place without scarring.
1. Sharply defined red and pink areas termed plaques.
2. Silvery scales due to light reflecting from the swollen stratum spinosum.
(a) Elbows, knees, scalp and sacrum are covered in thickly scaled patches
(b) Plaques of varying sizes appear anywhere on the body.
(c) Nails become pitted, ridged or separated from the nail bed. This can be the only evidence of the disorder in some people.
(d) Skin contact areas can be badly affected between fingers, axillae, groin, between toes, under breast, behind ears.
(e) The face is rarely affected
(f) The size of plaques and distribution varies so that different types are described. These are:
Commonest and least severe, with good prognosis. Responds well to UVR. Features:
1. Small multiple plaques are scattered evenly over trunk and limbs.
2. Often appears suddenly.
This principally affects scalp and body folds, although palms and soles can be badly affected. There is more severe inflammation and pustles are formed. The fluid contained in the pustules is sterile and must not be confused with the infected pustules of acne. UVR has limited success in this type.
The plaques join up and there is extensive erythema. The excessive distribution of blood to the skin can cause cardiac failure and loss of temperature regulation. This type does not usually respond to UVR.
Psoriasis clears completely with no marks but unfortunately can recur. There can be no sign in the evening and next morning it has started. It tends to be better in summer, worse in winter and recurs if the patient is worried.
This may be considered under:
1. General management.
2. Topical (application of creams/lotions to the skin).
1. A sympathetic, considerate approach is required together with reassurance.
2. Any anxiety or worry should be identified and the patient encouraged to relax or seek appropriate help.
3. Reassurance that it is not infectious or disfiguring must be given to both patient and family. Also an ’open door’ system should operate so that the patient can get to a dermatologist or physiotherapist immediately there is an eruption.
4. Dieting may be tried if there appears to be any allergy factor.
Many patients do well on topical treatment. Treatment may be:
1. Simple bland aqueous cream
2. Coal tar applications with salysilic acid abd zinc oxide in soft paraffin may be used alone or with UVR. The patient is usually admitted to hospital. The ointment is applied every day to the whole body except face and scalp. Every 24 hours it is washed off in a bath containing coal tar solution. If UVR is given, it must be after a bath because the yellow soft paraffin absorbs UVR. A suberythema general treatment is given daily using the Theraktin. This is the Goeckerman regimen.
3. Dithranol-in Lassar’s paste is used for resistant psoriasis. It is highly effective but can burn the normal skin. The patient may be admitted to hospital or treated as an outpatient. If the patient is applying the paste the physiotherapist should look out for blisters or reddish-purple stains on the skin and warn the patient of the danger. UVR with the Theraktin may be given in conjunction with dithranol as a daily suberythema dose. The paste is removed in a coal-tar bath before the UVR and is then reapplied afterwards.
4. Corticosteroid cream produces good results at first but when treatment stops the disease can be return worse than before. It is useful in an acute eruption and on the face and hands because there is greater absorption in moist areas. The dangers of side effects makes long term use inadvisable.
Retinoids, a variant of vitamin A – taken in tablet form produces marked improvement. Retinoic acid or etretinate is marketed as Tigason. Unfortunately, this produces unpleasant side effects such as dryness and cracking of the mouth, alopecia and pruritis. It is teratogenic (produces malfunction in a fetus), therefore must be avoided in pregnancy.
2.Cytotoxic drugs such as methotrexate are some times used in severe cases. These have dangers such as damage to bone marrow, intestinal and liver tissue.
Psoriasis can be treated very successfully with UVR. Two sources are used: the Theraktin and PUVA.
This is usually in the form of a tunnel with four fluorescent tubes. The patient lies flat for the treatment, therefore in order to treat the whole body the patient is generally naked and lies supine for half of the treatment session and prone for the other half. The spectrum of UVR emitted is 390-280 nm and peak emission is around 313 nm, therefore this constitutes UVB treatment. It may be used alone or in conjunction with coal tar or dithranol.
A sub-erythema dose is given daily or three times a week. The prominent parts of the body have a mild erythema which fades before the next treatment is due. The time is increased to maintain the reaction (e.g. 12 ½ % every 1-2 treatments). When the lesions start to flatten and heal the same time is repeated and the frequency of treatment reduced to twice weekly, once weekly and then once a fortnight.
The course of treatment may be spread over 8-12 weeks. These patients tend to deteriorate during the autumn and need treatment in the winter or spring. About 75% of patients with guttate psoriasis respond to UVB.
This is psoralen pluys UVA and is used for resistant psoriasis. Psoralens are photosensitizing substances eruption and on the face and hands because there which occur in plants such as parsley, parsnips celery. The one used for psoriasis is 8-methoxy psoralen (8-MOP). UVA is produced from fluorescent tubes, mounted upright in a hexagonal shaped cabinet inside which the patient stands throughout the treatment. The spectrum of UVR emitted is 330-390nm and peaks at 360nm – hence it is UVA.
Infra-red rays are also emitted and it is essential to have a cooling fan so that the patient can tolerate up to ½ hour in the cabinet.
The patient takes 3-6 tablets of psoralen preferably with milk 2 hours before exposure.
Duration of treatment
This may be 5 minutes at first for skin types 1 and 2 and progressed by 1 minute up to 15 minutes. It may start at 6 minutes and progress by 2 minutes up to 20 minutes for skin types 3 and 4. It may start at 7 minutes and progress by 3 minutes up to 25 minutes for skin types 5 and 6.
A record is kept of the total joule count. This is essential because there is an undeniable risk of malignant melanoma in patients who have been exposed to between 1500 J and 2000 J.
The patient attends three times a week until healing starts, then frequency of treatment is reduced to twice weekly, once weekly, once per fortnight or monthly ’holding sessions’.
Precautions, dangers, advice to patients on PUVA
1. Do not take psoralens on an empty stomach.
2. There is a real danger of cataract, therefore protective goggles are essential during exposure. Polaroid sunglasses must be worn from the time of taking the psoralen to at least 12 hours after. The psoralen is excreted in 8 hours but the effect of photosensitizing continues. The physiotherapist should test the glasses with a Blackray metre; 90% of UVA must be screened by the glasses. Patients are advised to wear protective glasses out of doors for at least 24 hours after taking the psoralen and also whilst watching television, a VDU screen or in fluroscent lighting.
3. The skin must be covered in bright sunlight and a hat worn for 2 hours after treatment.
5. If the skin is dry simple oil or lubricating lotions may be used.
6. Do not become pregnant or father a child contraceptive measures are essential during PUVA treatment.
7. A check-up is essential every month after completion of treatment.
8. During treatment if the patient feels faint the physiotherapist must be called immediately.
Mechanism of action
8-Methoxypsoralen binds to DNA and is activated by UVA. The psoralen binds to DNA thiamine bases, producing cross-linking which inhibits epithelial synthesis and cell division. In essence, therefore, the accelerated reproduction of epidermis in psoriasis is reduced, hence the beneficial results.
It may take up to 10 weeks to clear the skin and a further 4-6 weeks of maintenance doses may be given depending on individual response. Thereafter 2-6 monthly review is necessary. Once discharged, the patient should have access to treatment as soon as there is a recurrence.
This may be successfully treated by PUVA when the condition is on the soles and hands. They can be treated with a special piece of equipment in which the fluorescent tubes are horizontal and the hands or feet are placed on a grid over them.
10.5 Acne vulgaris
This is a chronic inflammatory disease of the sebaceous glands.
Age – It starts between 9 and 17 years, is associated with puberty and is generally clear by 30 years.
*** – Males are affected more than females although it may cause more distress to females in the age group affected.
Incidence – 80% of all adolescents have acne to some degree.
I. Puberty – Changes in the skin during puberty take place, the sebaceous glands secrete sebum, the hairs become coarser and sweat gland openings are wider. Some people have greater changes than others and are more likely to develop acne.
2. Lack of fitness, exercise or fresh air, poor health, constipation.
3. Diet high in butter, cream, sugar, chocolate or alcohol may have an effect.
4. Sweating, e.g. under long hair or a band around r/the forehead. Poor skin hygiene.
5. Endocrine abnormalities involving testosterone.
7. Skin type – dark complexion, heredity.
Bacteria, especially Propionibacterium acnes, infect the sebaceous glands and the glands increase in activity so that more sebum is released on to the skin.
1. Comedones – blackheads in the surface of the skin
2. sebaceous white worm-like material can be squeezed out of the comedone.
(a) Reddened round raised areas with comedone in the centre.
(b) Slight itching.
(c) Slight discomfort.
(a) Yellow raised areas with a comedone on the summit.
(b) Surrounded by reddish purple area.
(a) Purple coloured area which fluctuates on palpation.
(a) Small pitted areas; the extent varies according to the severity of the condition.
(b) Keloid, if the patient is unfortunate enough to have this type of tissue.
7. Distribution – face, upper chest and back.
Usually acne clears by 30 years of age. There are good results with treatment, although the disease tends to fluctuate. The lesions can be unsightly, resulting in loss of confidence and depression. It is very important to encourage optimism and prevent scarring.
An understanding approach is necessary because the patient who seeks medical help is undoubtedly suffering considerable distress and probably social isolation. Treatment may be:
1. Sulphur-based ointments.
2. Salicylic-acid based ointments.
3. Resorcinol paste.
4. Vitamin A acid gel.
5. Benzoyl peroxide gel.
These substances are applied directly to the affected areas. That there is a variety reflects the way in which different patients respond to different preparations. Benzoyl peroxide gel is more cosmetically kinder than sulphur-based ointments, which produce an erythema and peeling.
1. Antibiotics – These are used in pustular and cystic acne to clear infection and prevent scar formation.
2. Oestrogen therapy – This can help women whose acne is exacerbated just before menstruation.
This involves application of UVR and advice on fitness.
The source generally used is a high-pressure air-cooled mercury vapour burner (although success with a low-pressure burner using special shutters has been reported). This is housed in a reflector which can be angled to obtain maximum absorption of UVR with the patient supported in a comfortable position (usually modified sitting). The spectrum of UVR is 190-390 nm. The skin-burner distance is usually 45cm.
Two main schools of thought exist in the treatment of acne. In one the aim is to improve skin health and in the other the aim is to promote peeling.
Improvement of skin health
A first-degree erythema (El) is given 2-3 times a week for 3-4 weeks. The theory is that the maintained increase of arterial circulation provides extra amino acids, oxygen and other nutritive substances to enable the synthesis of healthy skin. Given that epidermal cells pass from basal layer to the surface in 3 weeks, the principle is that the treatment is given over a longer period. It is safe to give an El to the face, chest and upper back in the one treatment session. The patient with all areas affected feels that something is being done for the whole condition.
Promotion of peeling
A second- or third-degree erythema (E2, E3) is given and repeated only when peeling has stopped.
The theory is that affected skin is removed more quickly and healthy skin will replace it. The E2 or E3 will open up the pilo-sebaceous openings causing the infected material to be discharged rather than retained within the skin. It is not very pleasant to have a peeling face so an E2 is generally the maximum reaction aimed for. An E3 may be tolerated on the chest or upper back. An E2 can be tolerated to the face, upper back and chest but if all areas are red and sore at the same time the patient has difficulty lying down to sleep. Therefore, attendances are spaced to take account of this. The condition clears with this treatment in 6-8 weeks. If there is no improvement in 12 weeks it is probably wise to abandon treatment given that there is a danger of skin cancer with excessive UVR, and unlike the PUVA method there is no means of measuring the electromagnetic energy to which the patient has been exposed.
In both approaches some benefit is probably derived from the surface bacteria being destroyed by UVR and’spread of the condition is reduced. Also the patient responds to a humanitarian approach by the physiotherapist.
The physiotherapist may give advice to the patient as follows:
1. Follow faithfully any instructions from the doctor or dietitian regarding lifestyle, drugs and diet.
2. Take part in outdoor sport and shower scrupulously afterwards to remove sweat – sweat provides a medium in which bacteria thrive.
3. Wash the affected areas at least twice a day with oil-free soap and be sure to rinse well with cool water.
4. Remember that people tend to accept you as you are – face the world with a smile and no one (who matters) will notice the spots.
10.6 Mycosis fungoides
This is a condition in which there is a slowly developing T-cell infiltration of the skin with malignant lymphoma. There is chronic antigenie stimulation.
1. Lesions appear on the skin which are similar to those of psoriasis.
2. Distribution is different from psoriasis – often the face, particularly around the eyes is affected.
3. Tumours may form.
4. The disease may progress to the lymph nodes and vital organs.
The skin lesions respond well to PUVA treatment. The method is as for psoriasis. Patients wear goggles to protect the eyes so that the UVR can reach the facial lesions.
10.7 Polymorphic light eruption (PLE)
A condition in which patients have extreme sensitivity to UVR and visible light.
3. Papules and possibly blisters.
These appear after exposure to only very mild sunlight. The patient may have to live in curtained rooms or have special filter window glass installed.
The aim is to raise the sensitivity of the skin to UVR. PUVA greatly helps these patients. A course of treatment starts in February or March at low doses of 0.25-0.5 J. This is progressed slowly over 2-3 months to 6J. Patients who have followed this regimen have been able to enjoy Mediterranean holidays for the first time in their lives.
This is a condition in which areas of the skin are depigmented owing to loss of normal melanocyte function.
Irregular patches of skin become depigmented and appear white against normal skin.
The aim is to produce pigmenting of the abnormal areas. PUVA is very successful. Psoralens may be taken by mouth or painted on to the affected areas topically. The psoralen used may be tri-methylpsoralen (TMP) although 8-MOP was used for vitiligo before it was used for psoriasis. Exposure is as for polymorphic light eruption.
If a UVA source is not available, UVB from the Theraktin can be successful. A suberythema dose should be tried one or two times per week for 6-8 weeks. Note: if red spots or itching/burning sensations arise during treament of PLE or vitiligo the skin should be rested. When it has settled treatment should start again at one-half the dose and progress slowly. It is worth trying this several times because treatment can be ultimately successful even with these apparent setbacks.
10.9 Pityriasis rosea
This disease presents a rash of red or pink scaling macules on the skin of the trunk, often following viral infection.
Usually the disease is self-limiting but if it persists the patient may be referred for UVR.
Suberythema doses of UVB with the Theraktin two or three times a week for 2-3 weeks usually obtains good results.
Absence or premature loss of hair.
Alopecia areata – loss of scalp hair in patches.
Alopecia totalis – loss of all scalp hair and eyebrows.
Alopecia universalis – total loss of body hair.
1. Age – under 30 years.
2. *** – both ***es equally affected.
3. Predisposing factors:
(a) General anxiety.
(c) Poor health.
(d) Heredity (universalis is often congenital).
Alopecia areata or totalis may be treated by physiotherapy.
1. Hair becomes thin and falls out of follicles.
2. Hair follicles atrophy.
3.Sebaceous glands are less active.
1. Onset is usually insidious.
2. Clumps of hair come away in the comb.
3. Bald patches appear in which the skin is very white.
4. The patient can be very distressed, especially when new patches appear as others are recovering.
Fine downy growth may reappear in 2 months. The majority of patients recover in a year. Some patrents may not recover. The new hair may not be pigmented and feature as a white streak in otherwise normally coloured hair.
The aims are:
1. To improve general health.
2. To improve nutrition to hair follicles.
UVR given with the Theraktin may be givtn as a general body treatment. A suberythema or El dosage is given daily for 6-8 treatments. This is appropriate only if there is evidence of poor health being a factor in the precipitation of the disorder.
Promotion of nutrition
UVR given with the Kromayer may be given to individual patches. Dosage used may be an E2 or an E3.
Two or threes patches may be treated in one session and the patient may attend one or two times a week. It is important to remember that the patient has to sleep and an area of the head must be able to take pressure, therefore there has to be a plan or order for treatment of the patches.
The patient may attend for 2-3 months. If there is no sign of recovery after this time then treatment should be stopped and the condition reviewed in 2-3 months.
As soon as hair starts to grow in a patch UVR must be stopped to that area. As with all skin conditions, sympathy and understanding are important as it is very distressing for a young person to lose hair. This must not be confused with balding where there is receding at the temples and gradual loss from anterior to posterior which may well occur in young men whose father had exactly the same problem.
This is a condition in which the exocrine sweat glands are hyperactive.
Sweat pours out of the glands even during relative inactivity and in moderate atmospheric temperatures.
Distribution – palms of hands, soles of feet, axillae and trunk are affected.
It can be embarrasing and disabling, in that work with hands (sewing, baking, handling money or paper) is difficult.
Age group affected is 14-35 years.
If a patient is referred for physiotherapy, the treament requested is iontophoresis.
The principle is that the sympathetic nervous system activitates sweat glands, and the main transmitter substance is acetylcholine. Therefore introduction of an anticholinergic compound reduces the activity of the glands. Such compounds may simply be applied to the skin but their effectiveness is dependent on the amount of absorption, through the epidermis to the dermis in which the glands are situated. If a low-intensity direct current (l-2mA/in2 of electrode) is applied so that the anode is over a pad soaked in the compound (or in a bowl of water with the compound) then the positive charge of the anode repels the positive ions in the compound into the skin and they are effective at the glands. The cathode is placed proximal to the anode to complete the circuit. The current is applied for 15-20 minutes. Morgan (1980) recommends Glycopyronium bromide as a longer-lasting anticholinergic compound. Inevitably, there is scepticism about this treament and it may have limited effect on axillary hyperhidrosis. However, a croupier who had to handle chips at a casino was able to work by having 6-8 treatments every 9 months, until the condition cleared. In his case, the hands were placed one at a time in a water-filled plastic tray containing the anode and compound and his feet were placed one at a time in a water-filled foot bath with the cathode.
Patients report dryness of the mouth. If this is troublesome, the dosage should be reduced but patients tend to tolerate this for the benefit gained by the treatment. Sips of water during the treatment may help.