Sweaty hands

Palmar hyperhidrosis usually announces itself early. Most people with it recognise every line below.

• Both palms, evenly — often the soles as well
• It began in childhood, before you were twelve
• It stops entirely while you are asleep
• Paper, pens, phones and keyboards are affected
• You avoid shaking hands, or apologise when you do
• Stress makes it worse, but it happens without stress too

This is the Hyperhidrosis Disease Severity Scale — the same four-line scale used in the research and, for underarm treatment, in deciding whether you qualify for a rebate. Pick the line that fits.

The same wiring problem as the underarm, in a site with far more sweat glands per square centimetre. Palms and soles are among the densest, which is why the volume can be so striking.

It affects roughly 2 to 3% of the population. Among people with hyperhidrosis, about 65% have palmar involvement, and most have more than one site — four in five people with hyperhidrosis have three or more areas affected.

1. Start here

   Iontophoresis, ten minutes per hand. Four to five sessions across the first month, then maintenance every ten to fourteen days depending on how long your remission lasts. Adding a prescription anticholinergic to the water lifts the response rate to 80–85%.

2. Why home first

   A home device is $800 to $1,200 once. Injections are $3,000 to $4,000 every four to six months with no rebate. For most people the arithmetic makes iontophoresis the sensible first move, and it works.

3. If that fails

   Anti-sweat injections. The palm is sensitive, so this is done with a nerve block or with cooling — it is not the two-minute procedure the underarm is.

4. The trade-off

   Transient weakness of grip and loss of fine dexterity is common and expected. It settles over weeks. If your work depends on fine hand control — surgery, music, dentistry — we discuss this carefully before proceeding.

5. 4 to 6 months

   The effect fades and the treatment is repeated. There is no annual limit here because there is no rebate.

Iontophoresis works in over 80% of people who use it properly — and the qualifier matters, because it fails most often through inconsistent use rather than through being ineffective. It requires ten minutes, twice a week, indefinitely.

Injections work in over 85%, and the result is more complete than iontophoresis. Four to six months per treatment.

What will not change: tablets help only 15 to 20% of people and the dry mouth and sedation defeat most of them. And nothing available makes palms permanently dry without either ongoing treatment or surgery you would think hard about.

There is no Medicare rebate for treating the hands. Item 18362 covers severe primary axillary hyperhidrosis only. This surprises almost everybody, and I would rather you heard it now than at the desk afterwards.

Antiperspirants run about $15 a month. Iontophoresis is $90 to $160 a month in clinic, or a home device at $800 to $1,200 once. Injections are $3,000 to $4,000 per treatment, every four to six months.

Iontophoresis has none, beyond mild tingling and occasionally dry or cracked skin with heavy use.

Injections leave the hands tender for a day or two. The one that matters is grip weakness and reduced fine dexterity, which is common, expected, and settles over several weeks. Plan around it — do not book this the week before an exam, a recital or a busy operating list.