Where Are We At With Sweat? Part 2 (Excess Sweat/Hyperhidrosis)

David Curnow: When was at university, I lived in a residential college. That time was the heyday of some iconic sporting stars. You might have wanted to bend it like Beckham, maybe spin it like Warney, or fly like Jordan. There was another less known simile at my college, to sweat like guano. Just to explain a little, guano in that sense wasn't referring to bat poop, but instead it was in fact a nickname of a person who lived at the college. And that person was me. To sweat. Like Guano meant to sweat a lot, like David did. It was meant in moderately good humor, but highlighted the fact that as long as I can remember, I've always tended to leak more than even Washington's reflecting pool. Please don't paint me though. Hi, welcome to the podcast Where Are We At With, taking a look at pretty much every topic, one at a time. I'm David Curneau, aka Sweatman. If you remember our Where Are We At with Sweat, Episode, everybody does it, but at different rates. Some are barely noticeable, others should come with a permanent flood warning over their levels of moisture. Yeah, okay, no one likes the word moist. But it's not just a minor inconvenience for some people. Imagine packing several sets of clothes when you go to work each day because you'll need to change into dry ones every few hours. Or having constant problems with skin infections or fungal outbreaks, or not being able to hold a loved one's hand because of how wet yours is. It may not seem like that much of a problem, but anyone with hyperhydrosis knows that it can be debilitating. Professor Neil Simon is the co-founder and managing director of Sweat Clinics Australia. He also happens to be the head of neurology at Sydney's Northern Beaches Hospital, as well as the managing director and principal neurologist at Northern Beaches Neurology. Yes, he's a busy man, but don't sweat. He's here to tell us where are we at with hyperhydrosis? Neil Simon, thank you so much for joining us today.

Neil Simon: Pleasure, thanks for having me.

David Curnow: We're talking about something which affects our skin, at least in our minds, we think about sweating as being something that affects our skin. Why then are we speaking to somebody today who is, let's be honest, an internationally renowned neurologist, not dermatologist?

Neil Simon: well good question because the brain controls everything essentially, no, but hyperhydrosis, this this condition is is primarily a neurological phenomenon, and that is because sweat glands that produce the sweat are controlled by nerves which are in turn controlled by the brain. And when you sweat too much it's because the nerves to those glands are overactive, you know they're excitable which causes them to emit more sweat. So that's why neurologists are involved because we deal with nerve problems and overactive nerve problems and also we use some of the treatments we're familiar with the treatments that are used for overactive nerve problems which also happen to help with excessive sweating.

David Curnow: Mm. We'll get on to what is hyperhydrosis in a minute, but first, again along those lines, we mentioned neurology, some of your research is is in some pretty serious issues. We've got motor neurone disease, things like carpal tunnel syndrome, some stuff that really can be detrimental and damaging for people right around the world. Is sweating a bit much a bit of a step down?

Neil Simon: well so Motor neuron disease obviously in the news, really significant condition, devastating condition, and and I think that we'd all accept that that's a terrible problem and you know that's a very heavy part of my job. At the same time, people with excessive sweating suffer a lot with it in a different way and to a different degree, but it's something that's not trivial. It's something that causes a lot of problems for patients and who have it, or for sufferers. So yeah, I consider it as an important condition. For me it it's like I enjoy working in that space. I do it a so it's sort of a somewhat of a a cognitive break because I don't have to think about very complex neurological wiring and very d distressing degenerative illnesses which often neurologists have to deal with but at the same time it's quite rewarding because it gives these people who are suffering a lot a treatment option which makes them feel amazingly better and then makes turns around their life and that's nice to reflect in that the sort of the happiness that comes back when they follow up with you.

David Curnow: like a medical florist in a way, bringing joy to people as you deliver what you deliver. We'll get onto some of those treatments in a moment. Let's then talk about what I mentioned. What is hyperhydrosis? What how do we define it and I suppose diagnosis?

Neil Simon: Well so we all know that sweating is normal, it's a normal part of life. but what then constitutes normal and abnormal sweating is relates to that person's experience. So excess sweating, so normal sweating is you know, I need a bit of sweat to cool down. we have other functions of sweat, so it's not just a temperature regulation thing, but From a normal perspective, you know, there there is an amount of sweat that you need depending on the context. But then when you are not in those contexts, or perhaps you're in those contexts, but your sweat levels are much greater than everyone else's, then that would move into abnormal amounts of sweating. And hyperhydrosis is is essentially when you sweat more than you need for normal day-to-day life, and that it causes you. symptoms and suffering because of that. So that's that's sort of when it becomes a a con condition is when when the person who's sweating is like, this is this is causing me physical or or psychological symptoms as a result. I mentioned normal and abnormal and I probably shouldn't have used those terms because it sweating is still a physiological phenomenon. It's not sort of a disease per se. It's just that the drive to those to those sweat glands is heightened and and so you're getting more of that more of that physiological phenomenon that you need. So that's like hyperphysiological rather than abnormal I don't necessarily like the term abnormal.

David Curnow: Given the range of normal, given the range of human beings, that there there is quite a range. In a sense, sp sticking with the florist concept, is in a sense is it a bit like gardening where if I've got a tomato plant coming up in my marigold bed, it's a weed. But if the marigolds are coming up in the tomato bed, they're weeds, but vice versa, then they're not. It's a bit like that.

Neil Simon: Yeah, exactly. So people with hyperhydrosis, they're still normal people having normal experiences, but but the the their physiological process is just inappropriate for the context, inappropriate for the garden bed. You know, the the marigold marigolds in tomato garden beds are good, I believe. It helps keep some sort of bike away. But

David Curnow: yes, Okay, so yeah, I chose just about the worst example there. Marigolds protect tomatoes from all sorts of pests. Y you get what I was meaning though, right? will be on to be on for that one. You're right.

Neil Simon: that's okay, but but yeah, 100%. It's like a it's like having a like a bit of road a rogue pumpkin vine. or something, yeah, it happens. But it's everyone loves a pumpkin vine, but when it's in the wrong spot, it's it's not what you

David Curnow: My botanics have also been corrected here. Let's stick to more scientific things. one of the descriptions I I read about when we researched this was effectively that in a sense at times it's like your sweat glands are stuck in the on position. Is it a bit like that? Is that how we think of it?

Neil Simon: yes. i you so your sweat glands, you're right, sweat glands can be in sort of the off position where they're just inactive and not really emitting the sweat and then the neurological signals come in and they sweat. Now neurological signals are are driven by by the brain and the nerves and they respond to environmental conditions to say, it's hot now, I need to, we need some sweat to cool down. Or I'm I'm nervous, you know, my sympathetic system's activated. Part of that system is this fright, flight, fight response. And part of that is to get ready to do something vigorous. You know, like when you're when you're about to run off, you're the body's like, well, I better maybe I should cool myself down in advance of that. And because when I'm I don't want to be wasting time thinking about it when I'm trying to escape the saber-toothed tiger, you know? So that's then the sweat glands gets get turned on, they start emitting sweat and then then they get switch gets turned off when they're not needed. In hyperhydrosis, you that that switch isn't really regulated to the environment and it's sort of on either all the time, so it's continuous, usually in the wakeful hours, not usually overnight, but when you're asleep, which is interesting. And but it can also be intermittent. It doesn't have to be like permanent sun up to sun down or or eyes open to eyes closed. It can be that you do that you have it some days and not other days, or some parts of the day, not other parts of the day. But it it's when you do have it, it's exceeds what the triggers, what the environmental situation or whatever it is.

David Curnow: It's interesting, you mentioned there the idea of, I suppose, thinking about it, the idea of the the body or the brain making that decision based on inputs and what it sees or hears or or feels around it. But as you said, it it's it's not something we're thinking about. We're not choosing our brain, we're not making our brain do this. it's it's all happening under the hood, as it were. That makes it a bit hard, I suppose, to understand what's going on there.

Neil Simon: Well a really fascinating phenomenon which I've sort of been really curious about is some people particularly people with excess sweating of their hands they but it can happen in other areas as well probably the face as well is another common sight they will c Often report or say that when they think about they're not sweating, but they think about sweating and then they start sweating. So there's like a like a cognitive trigger to it, which is not sort of different to what you would think. We already talked about the environment and whatever else, but that's sort of not that's nowhere near the areas that might be responsible for heat regulation. That's that's a pure cognitive sort of psychic phenomenon that you think about something and then it happens. And That's you know, I find that quite curious and I guess it it speaks to that interplay with I'd mentioned already that flight fright flight, you know, it speaks to the interplay between the the sort of mind, memory, emotional areas which are all interlinked, and then these autonomic areas, which autonomic is this part of the brain and the nervous system that supplies things like sweat glands, blood vessels, that sort of thing. So they're all closely interlinked and that I guess phenomenon sort of speaks to that. And it also speaks to why people with hyperhydrosis often You know, like that there can be an aggravation in emotional situ like their sweat gets worse with in emotional situations or when they're busy or s you know, that that sort of ties in with that that sort of crosshair.

David Curnow: think I think even if you're not somebody who experiences this condition, I I think we've all experienced the concept of thinking of something often involuntarily, perhaps you just remembered something incredibly embarrassing and you're not deciding to remember it or deciding to react the way that you do in that cringe moment of of of shrinking horror because of what happened or your your body effectively your brain's taking over and making these reactions before you're even ready for them.

Neil Simon: yeah. Yeah, yeah, it's it's it's it's it's subconscious. It's it's not it's not deliberate, is it? You don't you can't you can't not you can't control your sweating, you can't tell your sweat loans not to sweat. It's not something that you could have have mental control over. But interestingly you can think about it and it makes it internal by themselves, so

David Curnow: Okay, there's a whole new field to explore there. Let's let's step back a bit to these basics though, because we did you mention the idea of sweating on the hands or the face. so let's clarify here. We'd heard in our recent sweat episodes that there are mainly two different types of glands. basically one that's more watery, one that's smellier and more oily. Are they both affected?

Neil Simon: they are both affected. So the you yeah, the the in in hyperhydrodies, yeah the b in both so the apocrine glands and the groin and the underarms are commonly they're common sites for people to have excess sweating, and then the the echoine glands and other parts of the body, including the Th the the they're the things that make it all the fluid, the watery sweat. And you know, maybe you could say that it's primarily the ekrine's watery sweat that ha happens in hyperhydro or primary hyperhydrosis. but everyone knows about stress sweat, you know, where you get sort of like get nervous, you get that sort of different like smelly sweat, you know, it sort of smells different and so it's like str stress sweat, that's probably more the apocrine. sweat, but yeah, I think that both of those glands can be affected and and you know it's sort of interesting they've they've got somewhat different nervous supply and the nervous supply have different chemical signals in them but yeah both can be affected.

David Curnow: And locations on the body. We mentioned the the fact that there are different clans in different places. Are there more common areas that this is an issue? Or as you mentioned, given that it's a partly about when it's a problem, both physically and emotionally, is it about areas that are more public facing, I suppose? w tell us about the areas that are more prone to excess sweat than others.

Neil Simon: yeah, so it varies per person. The sort of the common areas that a lot of people repor r report. Underarms very common. the fore in the face it's often the forehead across the The nose, upper lip are common, this part of the face less common. Scalp is super common, usually the the front bit and the back bit, you know, so like the band, not as much on the top, but you can have it all over. It's kind of curious that there's selective involvement of these areas. You thighs, behind the knees, back, chest obviously. I've got one patient, it was really fascinating. He had he had an underarm hyper hydrosis, I can't remember where else, but he had one little area on his chest, literally a like a several millimeter circle where it's just sweated out, like a like a drip, like a tap of sweat coming out of one spot in his chest. It was totally, totally bizarre. that it was just that the rest of the chest was dry, but just one spot.

David Curnow: So I I'm I'm struggling to understand the the the science of this. So effectively the brain is sending signals along the various pathways and in it is sending it inappropriately just along some.

Neil Simon: You can say it's being common. Yeah, right, exactly. So that's a good point. Yeah. W why is it that those particular areas are more more commonly affected? it's probably to do with networks in the brain, you know, what because things in the brain are are sort of networked together. so maybe that's an efficiency thing, so you can have one set of signals that happen and do do a collective job rather than having to turn on 10 billion switches, you can turn on one switch that that affects 10 billion areas, you know. but yeah, those those sort of sites tend to cluster together. I didn't say hands and feet, which is they're super common areas. So but you know, you can have people in the same family, and one person in the family has really bad underarms, underarms sweating, and the other person has bad hands and feet, and you know, it so it's so there's something there's genetic factors, but the way it expresses in the person and way their neurological system expresses it varies. but yeah I don't understand how the person had that singular point in the chest and how that would work from a network perspective, but it was yeah, it was very distinct. So there's a few mysteries for me anyway.

David Curnow: Imagining going behind the scenes at like a big data center or something with lots and lots of wires that are all coiled up together. Someone's been very careful about joining them together and there's one wire that just happens to be touching another one where there's a thin section of rubber and it's just getting that signal and sending it out the wrong way.

Neil Simon: Short circuit, yeah, it could be that, it could be that. exactly.

David Curnow: Hard enough when it's in your car, let alone in your body. okay, you mentioned the idea of in the family. Is this do we think it is genetically based?

Neil Simon: it's very commonly associated with family history. at least half of people who experience it would have a another family member who with it with the same experience or the same condition at least. Maybe their experience of it's different, but so there are some clearly some genetic contributions or susceptibilities, but you can have families, well, lack of a lot of genetic conditions where some are affected and others aren't. And certainly we see people who are who are the only person that they know of. Now, of course there may be other family members who have it and don't and it doesn't flag as a problem because they're like maybe they work outside and they don't care if they're a bit sweaty and and that doesn't mean anything to them. You know, like they're not a bit maybe they're very sweaty but they're working outside and it's sort of normalizing their industry and it doesn't really affect their job role and so they just go, I'm just a sweaty guy. versus someone where it affects them a lot. So perhaps that is a the that is a bit of family history is missed for the the sufferer because they're not they don't talk about it, you know? So

David Curnow: Obviously professionally it makes big difference if if you are a professional athlete, for instance, or or a dentist, the amount of liquid coming off you into a patient's mouth or whatever, is is certainly a difference w as opposed to somebody who's at training all day. So that's all that matters. Interesting, and because of course we did hear in our sweat episode that sweating itself is genetically linked in that you you are more likely to produce the same amount as

Neil Simon: Mm.

David Curnow: family members and that does travel there. So obviously there is part of that. It's not something, as you said, it's not a disease. This is not something you can catch or or develop as such.

Neil Simon: you can't catch it, it's not contagious. You can develop it. In fact it's it usually develops in adolescence or early adulthood, but it doesn't always develop then. I've certainly seen people who've developed the first symptoms later on in their life, like in their For example, so it's something that can develop, like I said, it may not manifest earlier on, but maybe manifest later. And presumably with adolescence, it relates to hormonal changes, driving, you know, contributing to sweat to sweating. But yeah, no, it's not something that's that's that you that you acquire.

David Curnow: Yeah.

Neil Simon: It's part of your makeup already, it's just where how it manifests or how it comes out.

David Curnow: Obviously puberty makes sense. That's when our body begins to be able to thermoregulate more appropriately, therefore that's when our sweating is going to be first noticed as to whether it's a problem versus kind of normal. But again, you talk about how our body changes during life, and yes, things like hormones, not just something like a a perimenopause, menopause, but also all sorts of other changes for both men and women, it can manifest later. Does that effectively mean that those are the two main times, adolescence and then perhaps middle age?

Neil Simon: so interestingly, so it's a so like primary hyperhydrosis, most people manifest before 25. You know, so there's only a small proportion of people who manifest later. so yeah, the the the vast majority of people would manifest at in young adult adolescents. Interestingly, that that's you that's people who, for example, primarily axillary underarm hyperhydrosis. experience people with hands and feet under sorry hands and feet hyperhydro hyperhydrosis they often have it present from a younger age so childhood like early childhood which is curious as well because it that speaks more to a primary neurological nerve overactivity thing rather than that hormonal influence so the that seems to be to for me and in my experience that seems to be quite a distinct separation that underarm hypohydrosis is a there's some sort of hormonal trigger to initiate it, whereas the other is is, you know, I think that's more primarily nerve network starts earlier, more tricky to deal with, that sort of thing. So yeah, that's that's quite fascinating.

David Curnow: Yeah. That's really that's that really is interesting. And you've mentioned a couple of times this and I I should have asked you earlier. You mentioned primary hyperhydrosis. What different types are there?

Neil Simon: yeah. So primary and secondary, making it keeping it easy. Primary means that it's just intrinsic to the body, that's intrinsic to the person. That is, it's the way it's the wiring that I've mentioned before. secondary is some other condition that that drives sweating. So for example, if you have infection, you've got you you've got fever as an infection, then your body gets hot and you sweat. You have you know sweats as part of a fever. So if you've got some chronic inflammatory disorder, you might have excess sweating, you might have a disorder of authority. Gland, for example, which which drives metabolism, which drives this the fright-flight-fight response that then drives the sweating as well. There are a variety of different conditions that can be associated with excess or increased sweating levels, but it's it's not caused by the makeup of the person, it's caused by the disease or disorder creating the conditions where you might sweat. That's secondary.

David Curnow: And for somebody who's walking into a clinic, Sweat Clinics Australia, for instance, hypothetically, just to name one of them that we have heard of recently, how do you determine that? How do you go about working out, look, this is just this is primary hyperhydrosis, or we feel this may be a symptom of another issue?

Neil Simon: Yeah, for sure. So if you have someone who who presents with a classic history, let's say they're they're twenty-five, they've had hyperhydrosis since they're since they hit puberty, it is it's in those typical areas, their general health is good, they don't have any symptoms of any other condition, then it's very likely to be primary. as a routine for a n for a new patient I would get a s some screening blood test to look for the various causes that might s thro slide under the radar, you know, it's probably low yield, but again, you know, I wouldn't want to miss a thyroid disorder, for example, because they can present for they can be chronic and be present for some years before they're detected. so yeah, I'd I'd just do a blood screen, but assuming the blood screen's negative, then we can be quite confident that it's primary. If I've got someone presenting later in life, for example, or that the nature of the sweating is a bit different, for example it's overnight, you know, like night sweats when you wake up in sweat, which is would be s mostly atypical for primary hypourosis, then I'd be looking a bit more intense intently for an an alternative cause. So that would that might that would change my diagnostic approach. So you'd be a a bit more of a an in an investigative, you know, you'd take a bit more of an intense investigative pathway.

David Curnow: Yeah. A a and if it is a pri if it is a sorry a secondary s a symptom of something else, do those conditions themselves normally present other symptoms in addition to excess sweat?

Neil Simon: No they would normally, yes. so, you know, thyroid disorders present with additional symptoms. you can have so if someone just presented with night sweats, for example, you would be but that would make me concerned that it's not primary hyperhydrosis and you would then you don't necessarily have to have other symptoms if you've got like a a grumbly infection somewhere or cancer or something somewhere, which is we certainly see people presenting where they seem mostly okay but maybe they present with night sweats or a bit of weight loss or loss of appetite, you know, but they've got something significant going on. So you do have to have a f a like a fairly good radar for that sort of thing so you don't miss an important condition.

David Curnow: We have any idea what sort of percentage of the population might experience this? And obviously that's couched in the terms of, as we said with the weed definition, it's hyperhydrosis if it's a problem, therefore i it's not super easy to measure. Do we know what sort of numbers there are though?

Neil Simon: Yeah, I think it's about usually around sort of like three to five percent of the population, so quite a lot of people. and yeah, exactly. And and that probably wouldn't capture those people who who maybe you know, if there's like a an ar an arbiter of sweating, like, that's too much, that's not enough. But there'd probably be people in the the ninety five percent who you could say, no, you're sweating more than than you should. but yeah, based on the definition of of the experience of the person three to five percent on surveys. So

David Curnow: a

Neil Simon: A lot of people in Australia, for example, have iodosis.

David Curnow: As immediately three to five percent of Australians, that's hundreds of thousands, right there, that we can think of. It's certainly quite a lot. Just quickly, three to five percent of Australians means about eight hundred thousand to one point four million. That's a lot. and as you mentioned, some people may be excess sweaters and not be a problem, some people maybe not sweat as much, but it is a problem to them in their particular circumstances. Professor Neil Simon is our guest, he's also a doctor, don't worry, he's the head of neurology at Northern Beaches Hospital in Sydney. He's also the founder and managing director of Sweat Clinics Australia, where the rubber hits the road, so to speak, or checking in on your sweat. We've mentioned the idea of the fact that this is effectively a neurological issue where signals are being sent in a way they probably wouldn't normally. Can that then be reversed and the brain not send the signals? Is there such a thing as the opposite of hyperhydrosis, not sweating?

Neil Simon: Yeah, anhydrosis. So there's a condition called anhydrosis where you don't sweat, or hypohydrosis where you don't sweat a a enough. there that's that's a bit of a mixed bag of conditions that that cause that. it's it can be like a brain there are brain conditions if you're if the the things that drive that thermoregulatory response aren't working properly. so there are some degenerative Disorders like neurological degenerative dementia type disorders where that area does of the brain doesn't work properly. There are some nerve disorders where the nerves that supply the sweat glands don't work properly. There are some genetic disorders where the sweat glands aren't created properly. And and then it can be from a it can be a phenomenon related to medication side effects and other things like that where you that's where the the signals are getting blocked, for example, to the sweat plant. So yeah, there is a there is a the the the opposite of hyperhydrosis is definitely definitely a thing. the the experience of the person it can be significant as well because you don't get that temperature regulation so you can then be subject susceptible to hyperplane you know overheating so that's definitely something that can be

David Curnow: And I guess in the old days they wouldn't have been able to chase down the antelope or run away from the creature because they weren't able to sweat enough and they effectively overheated. These days you could possibly spray yourself in the face with something and and get away with it. But but it is a i a similar issue. You mentioned the fact that night sweats tend to be less of a primary hyperhydrosis issue. Are there other times that we tend do they come out of nowhere like a migraine or a one nation political success, just blindsiding you with the craziness of it?

Neil Simon: So well so the the commonest situation is that it's it's mostly during the day, mostly when people are awake. you can have it in the evening when you're awake, but once you go to bed it usually stops. But the context when people notice it the most would be it's very common the experience it in the workplace because you're like switched on and your your brain's switched on, your body's switched on, your nerves are like more active. Maybe you've got to give meetings, you're a bit nervous about that. so that sort of is an additional driver to it, and it certainly can be a problem. We all know about exercise causing sweating, but interestingly I the My patients don't tend to focus on exercise because they're like, well I sweat but it you know, in the gym but it doesn't really matter because you know you're allowed to. but it's more in the other context, you know, socially that's a big problem and the workplace. And that's probably where that impairment comes from, that their social life is hampered, they're embarrassed, they're check body checking all the time. in the workplace, they've even though they're not feeling particularly nervous in their meeting, but Everyone they think that everyone thinks they're nervous because they've got big sweat patches on their arms and it makes you know ma makes them lose confidence in in their performance, you know, so so

David Curnow: Society does judge sweat a bit, we do, don't we? Subconsciously, even if it's we're not thinking about it, we we do tend to look at sweating as a bit of a negative.

Neil Simon: I think so, yeah. So it's got connotations, you know, of of s anxiety, nervousness, weakness, I suppose if you extend that and it's and that's probably where that's that's why people are besides the the discomfort and which is another important point, but I think that's a lot that's a a l a a lot of where the sort of psychological impacts of it come from, that people, you know, sort of lose their self esteem and are embarrassed and self conscious about that phenomenon.

David Curnow: That is obviously not a condition that can be treated with, say, medicine or surgery, that's very much a a mental, a cognitive challenge. D can psychology play a role in in the way that this is treated?

Neil Simon: Certainly if you had like let's just say had this the psychological the psychological manifestations sort of took a life of their own, then yes, 100%. You know, we we know that psychological management of medical conditions is important because medical condition has a spin-off impact on this on mental health, and you've got to manage mental health if that's impacted. Luckily, with this condition, if you fix the condition, then everyone's feels great. So you you you know, if you can sort them out for the condition then generally their their well being improves substantially. and you know it just depends on then how you know said the other mental health facets whether they need independence In my experience again, it's managing patients is that if you get on control of their sweating, their quality of life improves substantially.

David Curnow: Yeah. you mentioned there the idea of a little bit earlier about saying, just don't sweat or, you know, stop thinking about it or or stop making yourself sweat. Are there methods that people use to mitigate, I suppose? Better breathing clothes, cold shower, can they affect it? Or does hyperhydrosis short circuit that and and bypass those usual methods?

Neil Simon: the people that I'm dealing with probably that's insufficient for them because I'm sort of dealing with the pointy end of the spectrum. but yeah, absolutely, like excessive sweating can be managed by stress management techniques. So that, you know, which we talked about the psychologist before, if that's an issue, s a psychologist might be able to help with various types of met various methods to manage stress. types of clothing certainly can help, so like breathable, natural fabrics, n

David Curnow: Hm. Yeah. Yeah. Hmm.

Neil Simon: not avoiding certain partic certain styles of clothing. Some in fact it's very common that people complain that they can't wear the clothes that they want. So you could you can change your clothing, your wardrobe choices to minimize the impact that sweating has. And yeah, I guess that those sort of non-medical treatments are definitely definitely relevant. But yeah as I said from my perspective mostly people have tried that and hasn't been sufficient. Another really interesting fact, which I probably could have brought up before, but people often find that it's that people with primary hyperhydrosis, often cold weather is bad. You know, you think, cold weather should be good because you're not the it's all about hot weather and getting warm and sweating too much. But very often the sweating is significant or even worse in cold weather. And that's probably again because colder weather, you know, you're sort of like a bit, everyone knows you're a bit shivery and you're a bit, you're these sort of sympathetic nerves, the autonomic nervous system is a bit more upregulated in. So yeah, they can can drive sweet even though you think, I'll be fine in winter. These people aren't fine in winter, they are they're adjusting winter.

David Curnow: I think everyone's probably experienced at some point the feeling of a a drip of sweat coming down the middle of your back or something and and feeling it perhaps in a cool time when you maybe exercised or did something and feeling that it was inappropriate. I can imagine that having that cold drip of sweat when you are already cold, your body, brain, be highly attuned to that sensation and and and blasting out sirens and in a sense in a sense self sustaining the the process.

Neil Simon: Yeah, totally. Yeah, that's that's a good point. So you yeah, you go like what's going on and then you're a bit your brain's more aroused and then it drives it further. But yeah, then and it's obviously very uncomfortable when you're cold and wet. and that that sort of just compounds the situation. So yeah, that's that's definitely another context, I suppose.

David Curnow: Yeah. Okay, let's talk intervention then, because that is effectively the crux of of what you're doing, particularly at these sweat clinics. What is the process? This isn't a case of take these two tablets and you'll be fine for the rest of your life. Wha what what are you doing?

Neil Simon: Yeah, so look it you it's good to understand and I'm glad we talked about it, it's good to understand why what happens and what causes sweating because then you can understand how you might be able to fix it up. So you've got your sweat gland, it's got a the gland under the skin and then a hole out to the skin where the fluid comes out and then the nerve connected. And so you can basically approach it in all of those three locations. So you've got the hole coming out, you can say, okay, why don't we just put a plug in the hole? and so you can do that. You can put deod like aluminium based deodorant. The aluminium goes into the holes and blocks it. That's it. That's what antiposterins do, yeah. anniposts block the block the sweat gland, punctum to block the hole to so the sweat gets stuck there. and

David Curnow: That's what eighty perspirants are, basically just

Neil Simon: So that's the first option. In fact, that's the standard option. Everyone does that anyway before, but most people don't talk to the doctor about that. But there are different strengths of antiperspirant, different strengths of aluminium, aluminium chloride that you can use to, you know, if the basic version isn't working. Higher you go, the more you know caustic they are on your skin, so the less easy they are to tolerate. But yeah, that that would be the first approach because it's mostly benign, it does it's not invasive, it's mostly benign. you've then got I'll jump over the sweat gland for now, I'll come back to that. then you've got nerve signaling. So you can say, okay, we know what nerves sweat glands, we know what the chemicals that they s they use to control sweat glands. Why we we can block those nerve signals? So and you can block it by taking a tablet that blocks it. Or you can there's some newer treatments where you well there's some treatments that are coming onto market where you wipe on the the chemical that blocks the nerve signaling. And And that sort of diminishes those signaling so then the drive for the sweating is less. and yeah you can but then you've got potential for for side effects related to the chemical because those signals that go to the sweat gland also go to other areas of the body and so you know if you're not sweating then you're not you're not not got money. tears or not got saliva and so you know if you've got this is for tablets especially if you've got dry sweat then you're gonna have dry eyes and dry mouth so that's like and there are some other things as well but there are some drawbacks associated with it but that's one another approach and we use that sometimes in particular where the where it's all over the body because you know these topical treatments you can't lather your whole body with antiperspirant

David Curnow: Yeah. Ultra strength aluminium chloride or something like that. You can't take a bath in it and and

Neil Simon: Yeah, it's like over half. Yeah, exactly. But the and you wouldn't want to because we've talked about thermoregulation. If you blocked every single pore in your body, then no sweat's gonna get out and then you're gonna be hypo or anhydrosis. So when you if you take a medication, it might drop it down by twenty or thirty percent, enough to make it sort of manageable but still not a obliterative function, essentially. and then you can so an alternative to the tablets, like a chemical blocking of those nerves, is to actually disconnect the nerve from the gland. And and the way we do that is with a botulinum toxin, which people have heard of, probably most people have heard of it from a cosmetic perspective and Botox. and it is something that Disconnects the nerve from the gland, the nerve ending retracts, and then the chemical goes, and then over time, over months, the nerve grows back and then reconnects that gland and then starts again. And an interesting side fact on botulinum toxin, because everyone only thinks about it with toes and wrinkles, but that's actually fairly late to the party. It was originally used for medical purposes by ophthalmologists to correct. sort of la lazy eyes by injecting into the eye muscles. but so yes it's it's a it's a ophthalmological and neurological. It's called a neurotoxin because it's you know used to block those nerve signals but it's it started as a as a method to manage neurological and ophthalmological conditions. so that's a very effective treatment. It can only be used in small areas so like if it's a because you can't inject all over the body because it's too So there's a limit of how much of that toxin you can use in the body.

David Curnow: I say th injecting a neurotoxin into yourself willy nilly doesn't sound like a a smart life management skill.

Neil Simon: The whole yeah, the whole if you did the whole thing that would be really bad. But if you do it in localized area, it's super effective. Well it can be effective, I should say, and it's quite usually pretty easy to tolerate to the side effects. So that's that's another treatment option. there are some procedures where they we talked about the I talked about the gland, I skipped the gland, I'm gonna come back to the gland. There are procedures that destroy the gland. So there's they used to do and maybe they still do, but only very limited. surgical procedures where they cut out the the tissue that holds the glands. They literally did an operation, slice it out and just got rid of it. I see people who've had that done before. Usually patients are bit much further into the course of their condition. You know, they're usually older, but but it's quite significant as you're left with a bis decent scar and you know like post-surgical problems that can relate to that. There's a more modern there are more modern techniques to to destroy the glands using microwave technology and some laser technologies which are sort of emerging. so they're still pretty full on because you are like literally cooking your tissues. you know, the the sweat glands are got water in them and therefore they can heat up and you're gonna Thermoablate them would be the term. But yeah, that's another way you can deal with sweat glands. Again, you can only do that in very limited areas, like you're not going to go and thermoablate your facial sweat glands or chop out your facial sweat plans. Underarms certainly would be somewhere we might do that. But yeah, there's some targets, but it's you know not for everywhere. And you've got to sort of tailor the treatment to the person, where they're sweating, how much they're sweating, what their other medical conditions are. So they're the s they're the mainstays of of treatment in the various targets.

David Curnow: Obviously the idea of removing entire sections of our body, whether it's the sections that hold the sweat glands or or things like that or thermo ablading, as we say, that's quite invasive compared to tablets or even just a a single or a couple of Botox injections. How much difference is there there? When you'd see a patient or treat a patient, for instance, how long can it take?

Neil Simon: You mean how long can it take to get on top of the condition? well.

David Curnow: To literally give them a Botox injection that makes a difference. So how how long does it take for that to to in your clinic if they happen to be there?

Neil Simon: so like those procedures, like botulone toxin procedures are quite quite quick. You know, you've got to depending on the area and how many injections you have to give, they're quite speedy and it doesn't take particularly long. Depends on that patient as well, 'cause it's unpleasant to have needles strapped into you, but yeah, that can be very quick a f handful of minutes. it's yeah, that's a that's a very efficient proced process.

David Curnow: And how quickly does it take effect?

Neil Simon: usually one or two weeks would be sort of standard. some people have some people say that they notice the effects the very next day and other people say you know maybe maybe two weeks, maybe a bit longer, and and that probably d it depends on exactly the makeup of that the the junction between the nerve and the gland because it's it's a protein chemical that that goes in and binds into the or joins into the the the junction and then sort of cleaves it so that like if your protein structures are slightly different then that thing might have a bit more trouble finding its way in there and and separating it versus someone who might have very like a perfect match for example. So but yeah it does vary but yeah that sort of a few days to a couple of weeks would be standard.

David Curnow: And then how long does the effect last for?

Neil Simon: again, it's that's that varies a lot. It it's mostly about three and a half, four months would be sort of standard, and then some people go for longer six months or even longer than that. And in general, like in in in muscle, which is what I mentioned it sort of started as a treatment for to try to disconnect nerve from muscle. we the sort of the the research they they sort of done experiments where they've injected it and then looked at over time the regrowth of of neuromuscular junction and that's typically around three months on average. Sweating seems to be a bit longer, you seem to seem to last a bit longer. And I'm not sure whether that's specific to how it reconnects or whether it's because there's more than there's more factors that we've already talked about in sweating. So when you're when you haven't sweated for a a half handful of months because your nose are disconnected, then your brain's not is not thinking about it. And so then might take a while to sort of realize, hang on, I'm sweating again, and then that those brain processes that that can make it worse maybe take a while to kick in as well. But I'm not I'm not entirely sure but that seems to be an observation between treating a muscle problem and treating a sweat problem.

David Curnow: think about this as perhaps a bit of a modern issue in that identifying that this is a medical condition, not just some people happen to sweat more than others, and there's a reason neurologically understanding the way that that works. What are some of the big steps that have been taken research-wise in in since you've been working in this, that have perhaps made a difference when it comes to both the understanding of and treatment of the condition?

Neil Simon: yeah, so it's something that I guess we've had a fairly good understanding of that physiology that I've mentioned. A lot of that sort of neurophysiology of of neuroanatomy and neurophysiology was has been well established. so that's been known about and and we know we've known sort of why or or the the mechanism for sweat production and the like. as you mentioned, I think that partly it's sort of the recognition of it as an important thing. which has been a more recent phenomenon. So that's probably what I what I you know, that the the awareness, people appreciating that it's a like the proper thing, that it's not it's not somet that's not nothing, something to be swept under the carpet or don't worry about it. I think that that and that reflects other changes in in you know mindset in healthcare, v validating conditions that affect people substantially even if it

David Curnow: Yeah.

Neil Simon: even if it may be something that you can't see, you know. For example, migraine is a great example of that. You know, it's a condition that it's really horrible for people to have them, but you can't see it. You know, you can't measure it. And you see people like, it's just a headache. No, it's not, it's really a debilitating condition. So I think it's probably that same phenomenon where we're going, okay, these are all important things. These are people who are suffering. You know, sure maybe sweating for someone's not that imp not it doesn't bother them, but for all these other people it does. And that's been probably the main change that that I've seen, you know, is that I said that sort of validation of it as a proper issue and awareness of it. In terms of

David Curnow: Yeah. I I don't wish to conf sorry, I don't want to c to conflate the issues, but it speaking to somebody recently about menopause and perimenopause and the understanding thereof and the fact that it's no longer being just swept under the carpet and just just deal with it, move on. The fact that there is an impact that is not just physical but is psychological or is emotional. I i there is that societal awareness that that grows, I suppose.

Neil Simon: Yeah, that's a another good example of a of a an apparently sort of silent condition. You can't sort of see it, but it's affecting a lot of people and and being and increasingly the awareness is the awareness is increasing that that it's a that it's a condition that needs proper attention. So in terms of sort of like the science, there's I I mentioned some of the that product development in terms of treating the treating hypohydrosis. So there's that's probably where, you know, like now we now we say it's a proper condition and we need to have proper treatments for it and and a s a variety of treatments, some options available because not everything works for every single person or they may not be able to tolerate it or you might not tolerate the topical treatments and you might say, I couldn't bear to have needles jabbed into me. Okay, all right, well we need to come up with something else, or you know, the the pills you might mightn't be able to handle them because you're on other medication so maybe the the localized treatment is better for you so I think having some options available is is great and that's probably you know that's something that seems to be moving in at the moment and yeah

David Curnow: In terms of questions that perhaps are unanswered at the moment, what are some of the big ones that you'd like to see answered or perhaps are are confident may be answered in the next five years or so? Some of the some of the main ones that would be good to know.

Neil Simon: Well look. I'm a Like I'm a neurologist and I sort of am interested in in all those unusual workings of the brain. So I already mentioned some of these strange things which I don't fully understand. I just for even for academic sake, I'd love to understand how the brain works a bit better, and and there's a few specific phenomena in hypohydrosis that you know might illuminate that. And and you know, the the brain is the sort of the final frontier of medicine. So perhaps not directly related to hypohydrosis, but related to to my career more broadly, like it would be wonderful to understand the brain a bit better. And I think if we understand the brain a bit better, then we might be able to understand why when you think about sweating your hands start sweating. So maybe that's a good start. I'm not sure about five years though. That might be something that that outruns me but.

David Curnow: Happy to check back with you in five years and see. Finally, I I'd like to finish off something when we first spoke, you mentioned to me, and I mentioned this as the florist, the idea of somebody bringing joy. What is the reaction like? If somebody has, say they're fifty, fifty five, they've been a a person who sweats a lot their whole life, perhaps having to change clothes at work, unable to do certain things, and with a few injections you can magically make that change. What's their reaction like?

Neil Simon: That's a that's a good scenario because we very often see people who are have had it for decades and they and they come in and they go, I didn't know there was a treatment for this, you know, like which is strange. You know, you think, wow, you've suffered with this all this time. Or they like I wish I had a had this treatment when I was at school because I used to Like I you know, it's clearly impacted their life so much. but you know the thing that stra again I find this a little bit strange, but spontaneously people come in and say, that was life-changing. You know, they they that's the the term they use, life-changing, which you know, it's as though we've sort of given them a promo flyer on the way in and you know we want to use it for our next, you know.

David Curnow: Check around for the cameras filming the filming the advertisement.

Neil Simon: Yeah, exactly. And like yeah, Insta, can you just say that again, you know? we don't do any of that, but that's what they say, it's life changing. So and they s they're quite sincere about it and and so something that's again for people that say, it's not an important problem, like not important problems fixing a non important problem doesn't make someone think it's life changing, but these people are are genuinely, you know, their life is revolutionized with treatment.

David Curnow: Yeah.

Neil Simon: whatever that might be. So yeah, that that that's probably the most common description. But in general, everyone's very, very happy with it and it really enlightens their you know, if you don't have to worry about that, you've got less we've got too many other things to to stress out about and if you don't have to stress out about sweating too much, then you can focus on One Nation or or what or Donald Trump or whoever whatever else you want to do, you

David Curnow: Yeah, let's not set our sights too high for the things we should worry about. Either way, try not to sweat the small stuff. and if you do have a problem with sweating itself, you can probably think about that as well. Doctor Doctor, Professor, Neil Simon, all of the above. thank you very much for your time today.

Neil Simon: Pleasure, thank you.

David Curnow: So around a million Australians means it isn't a small problem, but as we heard there from Professor Simon, it can often have a relatively simple treatment for at least a period of time, which is more than we can say about other debilitating health issues. A big thanks there to the incredibly busy but generous Professor Neil Simon. On our website, you can find links to his research as well as his Sweat Clinics Australia, and of course a transcript of this episode. Obviously if you're someone who thinks they may benefit from treatment, you should speak to a GP, we're not a doctor, obviously. Those GPs can refer you to someone they recommend for the condition. Thanks for listening. I'm David Curho. Goodbye.