BACPARNovember 2015

Iontophoresis for amputees

Sweaty stumps

Julie HalfordRGN

The Hyperhidrosis Support Group UK

Primary Secondary(Focal) (often generalised)

• Overstimulation of the sympathetic nervous system. Specifically, the Thoracic Sympathetic Ganglion Chain, which runs along the vertebra of the spine inside the chest cavity.

• It affects both sexes equally and all races; but Japanese suffer more than most

• Affects at least 1% of the population

• Palmar and Plantar hyperhidrosis are the most common, followed by axillae and facial

Not present when asleep

Childhood or adolescence onset

Family history in about 1/3 of patients

Always bilateral

Amputees

Sometimes unilateral

Infection present

Drug induced300 reported medications. Especially Antipsychotics, SSRIs & Progestogens. Also illegal, especially Cannabis.

Injury induced

Metabolic, Neurological or endocrine disease – Heart disease, Malignancy, Diabetes, Thyroid, spinal cord injury,

Parkinsons, CVA & Menopause,

3 million eccrine sweat glands – Hands, Feet & axillae

Primary Hyperhidrosis

Reasons why amputees sweat more

• Use more energy to carry out activities.

• Loss of skin surface on the body. The skin helps control body temperature as it is through the skin that perspiration is released, allowing the air to dry it and cool the body. When a person has an amputation, he/she has less skin surface and, therefore, the remaining skin surface makes up for the lost skin surface by perspiring more.

• The sockets of artificial limbs cause sweating. Air cannot reach it to evaporate sweat.

• Problems with sweat become a bigger issue for amputees with high level amputations or with multiple amputations. Amputees with high level amputations or with two or more amputations naturally use more energy to carry out tasks and thus create more heat in the body that is then released as sweat. Because of their amputations, they also have much less skin surface through which to dissipate the perspiration.

Self help

Antiperspirants

Prosthetic sheaths & stump liners

Clean stump & socket regularly with emollients and warm water. Best to wash the stump and socket at night before going to bed. If you do it in the morning and then put on the artificial limb, the stump, even though dried, is still probably clammy

Freshening up by removing the artificial limb for just a few minutes partway through the day and cleaning the socket and stump enhance the amputee's ability to go through a day without getting soreness from sweat buildup.

Secure wipes (Glycopyrromium Bromide wipes)www.pharmacy.ca

Manjana t-shirtswww.esteemclothingprotectors.co.uk/man-v-classic.html

0.05-1% Glycopyrromium Bromide in aqueous creamMade up by some pharmacies - short shelf life. POM

Glycopyrromium Bromide (Robinul) cream Nova laboratories. POM

Sweatstopwww.sweatstop.co.uk

Must be applied to completely dry skin in the evening before going to bed. In order for the solution to permeate the sweat glands and salts to close the sweat glands it is very important to avoid anything that could lead to sweating in the hours following application.1. Wash the affected area and let the skin dry completely2. Spray - spray once (or spray onto a piece of cotton wool and dab onto the affected area)3. Roll-On - Shake before use and roll once4. Lotion - apply a small amount to your finger tips and massage onto the skin. You can vary the effectiveness by using more lotion and/or rubbing for longer5. Let the product dry before getting dressed to avoid staining your clothes and rubbing the product off the skin

• 1. I don't baby it. I get a bit of sun on it when I can, I towel it roughly, I wear my leg all the time (unless there is an extreme problem).

2. I keep the hair on the leg trimmed extremely short. I use an electric clipper (set on ZERO with no guard) to do this. I do not ever shave with a blade - this will lead to ingrown hairs for sure. The point of keeping the hair short is that it improves my fit, improves my suction, and therefore less problems arise.

• 3. As soon as I feel any problem arising I use a dab of vaseline on the area until it goes away. -I don't wait for it to get worse before acting.

4. If I am heading out to do something challenging I will put several Tegaderm dressings on key spots to protect the skin & use a strong antiperspirant. In long races I stuff a chamois in my race belt and use that for drying my leg. They are light small and very absorbent.

• If I get a problem I use Cicatrin (NEOMYCIN SULPHATE) if I have a problem. This is a prescription powder that speeds healing. It is extremely fine and a tiny amount will do the trick. I put it on every chance I get to heal the problem. Especially good at night

Meyrick Jones is an international calibre ParaTriathlete, ParaCyclist, and Para Nordic skier

Iontophoresis – when is it suitable?

Hyperhidrosis of the:

Hands

Feet

AxillaeChest/back

Groin

Stump following amputation

Iontophoresis for the hands, feet & axillae

85% success rate using just

tap water for hands & feet.

70% for the axillae

Usually done once a week

after initial treatment

sessions of 7 sessions in a

4 week period

Bicarb of soda may be used

if tap water fails

Robinul can be added to

the baths if bicarb fails

Iontophoresis use for other areas

Excessive sweating on chest & back following ETS

Various small studies have been done on amputees using iontophoresis, but

only one written up. The Efficacy of the Drionic Device in the Treatment of Hyperhidrosis in Juvenile Amputees

K. TEDFORD, J.. ENGSBERG, S. FELLOWES, R. BALLANCE, AND J. A. HARDER

Headley Court in Surrey did a small trial on iontophoresis for stumps using an idrostarmachine. The achieved good results. However, botox is quicker if you have the funding!

Mains or Battery?

Iontophoresis machines & electrodes

Battery

Most machines are rechargeable, or use rechargeable batteries

Won’t give dangerous shocks

Gives similar output as mains and just as effective

Portable

Mains

Risky?

Has been known to give shocks

Not recommended in Electrical storms

Supplied to several UK hospitals with good results

Iontophoresis machines & other options

Only 2 people in Europe use this option as far as I am aware, but it works well. Specially manufactured for these patients and very expensive

I am now in discussion with the manufacturers of the Idrostar machines who supply to most UK hospitals & patients to see what they can come up with.

I hope they will have something for sale in the next few months and it will be considerably cheaper than this optionSO, IF YOU’D LIKE TO KNOW WHEN THESE

BECOME AVAILABLE, THEN PLEASE LET ME HAVE YOUR EMAIL ADDRESS & I WILL LET YOU KNOW

Water and Iontophoresis

• Some areas get better results than others. Why?

• There have been no conclusive trials to date.

• Bicarb content in water is probably a major factor

• Bottled water with high Bicarb – Badoit

• Add 2 teaspoons of Bicarb of soda to water

• Calcium may also play a part

Doesn’t work for everyone, but worth a go

• Electrical current & mineral particles in the water act together to thicken the outer layer of skin, thereby blocking the flow of sweat. Once output is blocked, or interrupted, sweat production in the treated area stops

or• It may temporarily cause a functional impairment of the sweat duct;

either by completely blocking sympathetic nervous system transmission to the gland, or changing the cellular secretory physiology.

or• Some believe that it causes a plug on the sweat gland and others

believe it induces an electrical charge in the gland that disrupts secretion.

• Decreases ph in sweat duct which may contribute to eccrine gland disfunction. (Saline is not as effective as tap water)

In other words – we don’t really know!

IONTOPHORESISHow does it work?

CONTRAINDICATONS

• CARDIAC PACEMAKERS & CARDIAC ARRHYTHMIAS

IN LINE WITH CURRENT FLOW

• METAL ORTHOPAEDIC IMPLANTS - SMALL PINS ARE ACCEPTABLE. IN LINE WITH CURRENT FLOW

• PREGNANCY

• INNABILITY TO FEEL SENSATION – PERIPHERAL NEUROPATHY

Botox for amputess• Numerous studies name BTX-A as a safe and effective treatment for

hyperhidrosis

• (Naumann, Hamm, & Lowe, 2002; Charrow et al., 2008; Grunfeld et al., 2009; Schlereth, Mouka, Eisenbarth, Winterholler, & Birklein, 2004; Vadoud-Seyedi, & Simonart, 2007, ).

• Works by interfering with the effect of neuro transmitters and

paralyzing the sympathetic nerves

Botox is a successful treatment for hyperhidrosis of a stump, but treatment is rarely available on the NHS

Drugs – POM’S

Oxybutynin modified release (Lyrinel XL) 10 mg

Oxybutynin Start with 2.5mg BD and increase if necessary. (take at least one hour before meals)

Propantheline (Pro-Banthine) The only licenced anticholinergic/antimuscarinic in the UK

For some, being wet is fun, but for others, it is a constant living nightmare

Thank you for listening

The Hyperhidrosis Support Group

for Patients and Medical Staff

• WEBSITE: www.hyperhidrosisuk.org

• EMAIL: info@hyperhidrosisuk.org