Residual Limb Hyperhidrosis
Many people with limb differences who rely on prosthetic devices struggle with residual limb excessive sweating. This type of hyperhidrosis can severely impact skin health, prostheses function, mobility, and even safety. Fortunately, there are treatment options to help, and healthcare providers who are working on future innovations.
Huge thank you to Dr. Mary Maiberger, Chief of Dermatology at the Veterans Affairs Medical Center in Washington, D.C. (among many other achievements and titles*) for informing this page and helping us create a continuing education video all about the management of residual limb hyperhidrosis.
In the United States alone, there are more than 2 million people living with limb loss. That number is predicted to jump to 3.6 million by 2050. Most amputations (65%) involve lower limbs.
Surprisingly, only 5% of lower leg amputees wear their prosthetic devices for more than half of their walking day. There are a variety of reasons for this, but certainly excessive sweating (hyperhidrosis of the residual limb) and related skin irritation are a big part of the issue. More than half of people with an amputation say that they experience discomfort with their prosthesis related to heat and sweating.
Research shows that among Vietnam veterans with amputations, even 38 years later, skin complications continued to cause them significant problems. Other research has shown that hyperhidrosis is the most-reported skin issue in patients with lower limb amputation and often leads to other problems like odor, swelling, irritation, maceration (skin breakdown), ulcerations (skin wounds), and infection.
One of the challenges is that to achieve a secure fit, prosthetics must be worn snuggly. This leads to heat, sweating, and moisture build-up inside the prosthesis. As sweat accumulates in the prosthesis, it can slip, compromising function and mobility, and increasing risks of falls and skin irritation.
To help prevent or manage excessive sweating in the prosthesis, it’s important to start with the prosthesis itself. Ensure there is a liner or sock/sheath that can absorb sweat and offload some heat. So far, silicone/polyethylene liners seem to work the best at this, but, in the future, there may be more improvements or new options. Patients can also wear additional sweat absorbing bands in the socket. Ask your healthcare provider, prosthetist, orthotic expert, and occupational or physical therapist for options and ideas.
To treat excessive sweating of the residual limb, antiperspirants, applied at night to completely dry skin are the first line. Antiperspirants have the benefit of being inexpensive and readily available. Prescription antiperspirants, such as Drysol, are the most likely to be effective, says Dr. Maiberger, but can cause skin irritation so should be used as directed and with caution. Discuss best practcies with your healthcare provider, and follow our tips and for prescription products.
The prescription topical anticholinergic (glycopyrronium) cloth (Qbrexza) has, in a small number of patients followed, shown some benefits for residual limb hyperhidrosis but there is concern that potential anticholinergic side effects could be magnified due to the larger areas being treated (larger than the underarms for which Qbrexza was designed).
Just as topical anticholinergics in the form of Qbrexza can have a role in treating residual limb hyperhidrosis, so too can oral (by mouth) anticholinergics. These medications decrease sweating all over the body, not just on the residual limb, and are often used in combination with other treatments for treating various types of excessive sweating. But due to potential side effects, and the fact that many amputees may have a medical condition that contributed to their amputation in the first place, there are many people with limb loss for whom the risks and side effects of an oral anticholinergic won’t be a good choice. And while sweating can decrease in amputees taking oral meds, in research the risks of skin problems don’t seem to decrease proportionally.
Botulinum toxin injections (like Botox) are probably the most studied treatment for residual limb hyperhidrosis. Healthcare providers typically inject 300-500 units of a botulinum toxin product in a circumferential pattern, 1–2 centimeters between each injection, to cover approximately the farthest 3 cm of the residual limb. The treatment needs to be given about twice per year and is usually focused on the warmer months of the year. Sweat reduction lasts about 3-4 months. Botulinum injections can, however, be painful and insurance coverage (and out-of-pocket costs) can be an issue. For pain, healthcare providers can use topical numbing medications or ice. For help with navigating insurance and reimbursement, talk to your healthcare provider and review the resources here.
Some patients try iontophoresis for residual limb hyperhidrosis, but - so far - this seems to be less effective for residual limbs than for hands and feet. And because there are no iontophoresis devices designed for this purpose; treatment logistics are difficult.
Small studies have found that laser hair removal (like NDYag or Diode) can be helpful and improve quality of life for amputees with hyperhidrosis. Ridding the residual limb of hair can limit friction and decrease heat retention in the prosthetic device. The laser hair removal process can also damage sweat glands so that they produce less sweat. For those with folliculitis (inflamed or infected hair follicles) this can be especially useful. “We had one patient who was having a lot of sweating and folliculitis in the amputated limb interfering with quality of life,” says Dr. Maiberger, “We did laser hair removal and that resolved the folliculitis and also helped with the sweating significantly. The patient is now able to wear the prosthetic limb without significant sweat.” Keep in mind there is not a lot of research on this option, yet, but if it interests you, please discuss it with your healthcare provider.
There’s not a lot of research on this option, yet. If it interests you, please discuss it with your healthcare provider.
Microwave thermolysis (miraDry) can also be used to treat residual limb hyperhidrosis. miraDry permanently destroys sweat glands to stop sweating and is an FDA-cleared treatment for underarm excessive sweating. Local (targeted) anesthesia is needed for this treatment, like a nerve block. Results have shown 80% reduction in hyperhidrosis in amputees. But only half of a limb can be treated at a time (to prevent dangerous swelling called compartment syndrome) and so two treatments are required. Each treatment can take 7-8 hours. After the procedure, approximately two months of recovery are needed before a prostheses can be used extensively again. This time commitment, as well as cost, can be a limiting factor for many patients.
Given the vital role of prosthetic devices in helping amputees maintain their quality of life—including work, social, and recreational activities—and the impact of excessive sweating on skin health, prosthetic comfort, function, and safety, it is crucial for healthcare providers and prosthesis users to work together to find treatments and combinations of treatments for residual limb hyperhidrosis.
From moisture-wicking liners and antiperspirants, to medical treatments like botulinum toxin injections, topical anticholinergics, oral anticholinergics and microwave thermolysis, there are treatment options for you and your healthcare provider to consider and tweak, to find the right combination for you.
More research and innovations are needed, but today’s interventions can have a dramatic impact and help amputees make the most of their prostheses for movement, independence, self-confidence, and so much more.
*The expert advice and insights in this article have been informed by Dr. Mary Maiberger, Chief of Dermatology at the Veterans Affairs Medical Center in Washington, D.C.; Associate Professor of Dermatology at The George Washington University School of Medicine; Associate Clinical Professor of Dermatology, Howard University School of Medicine; Assistant Adjunct Clinical Professor of Dermatology, Uniformed Services University of the Health Sciences; Clinical Instructor of Family Medicine, Georgetown University.
Healthcare professionals interested in a continuing education course on treating hyperhidrosis of the residual limb, led by Dr. Mary Maiberger, can click here to access the course. Registration is required, but both the registration and program are free.