Iontophoresis — how to get successful results

CLINICAL SKILLS
Iontophoresis — how to get
successful results
Julie Halford
Primary hyperhidrosis (excessive sweating) is an embarrassing and disabling condition affecting at least 1%
of the population (www.hyperhidrosisuk.org). Iontophoresis, which passes a low electrical current through
the affected body part, is a treatment widely used throughout the UK in dermatology departments and
some vascular and physiotherapy departments.There is little scientific data to explain why it works, however
it is considered a safe and effective treatment for the condition.This article looks at the best methods and
protocols to ensure successful results and includes quick set-up guides for practitioners’ easy reference.
KEY WORDS
Iontophoresis
Tap water
Robinul
Hospital use
Hyperhidrosis
Primary hyperhidrosis is an embarrassing
and disabling condition affecting at least 1%
of the population (www.hyperhidrosisuk.
org), mostly in their hands (palmar, Figure 1),
feet (plantar) and axillae (armpits).
Hyperhidrosis is linked to over-activity
of the sympathetic nervous system.
Specifically, it is the thoracic sympathetic
ganglion chain, which runs along the
vertebra of the spine, inside the chest
cavity.This chain controls the apocrine and
eccrine glands.The eccrine sweat glands
are responsible for perspiration throughout
the entire body and, when the chain is
over-active, it causes excessive sweating at
most times during the day.This in turn may
cause considerable social, psychological
and occupational problems, involving the
sufferer to be either ostracised or bullied
by their peers.
In primary care, patients are
generally prescribed aluminium chloride
Julie Halford is a Sclerotherapy Nurse Specialist
for Hampshire, Oxfordshire & Buckinghamshire
and founder member of The Hyperhidrosis
Support Group
10
antiperspirants (most helpful for axillary
hyperhidrosis), but many find these
are either unhelpful or cause irritation
(Charlson, 2006), so are then referred for
secondary care (Lowe et al, 2003).
Iontophoresis is most commonly
used for successfully treating the hands,
the feet and the axillae, but has also
been employed in other areas of the
body, such as the back and chest, and
for compensatory sweating following
endoscopic thoracic sympathectomy (ETS)
(Davies, Lawton, 2009).
Most dermatology departments in
the UK now provide an iontophoresis
service for patients with palmar and
plantar hyperhidrosis, but not all provide
a service for those suffering in the axillae.
This is because Botox is still available on
the NHS in some hospitals for treatment
of the axillae, although less and less so, and
also because some departments just do
not have the manpower to take on any
more work. Patients are often treated with
one course of iontophoresis (7 treatment
sessions) in a hospital setting, then buy
their own iontophoresis machine for use
at home.
Figure 1. Primary palmar hyperhidrosis.
Machines used in UK hospitals tend to be
The Idrostar Pro Pulse (Direct & Pulsed
current),The Iomax 4 (Direct current) and
The i2ma (Direct current).These all come
complete with a set-up manual and DVD.
Most patients buy either one of these or a
small Idrostar machine for home use.
Recently launched by STD
Pharmaceuticals is a new iontophoresis
machine for patients to use at home,
which is both Direct (DC) and Pulsed
(PC) current. It is called the Idrostar +.
This little digital machine will treat hands,
feet and axillae and can be used on
sensitive skin, and on children. It comes
with a remote control for patients’ ease
of use.
Treatment methods and protocols
Iontophoresis machines
It is important to ensure the patient has
read the information leaflet and signed
a consent form before commencing
treatment (available from The
Hyperhidrosis Support Group).
Iontophoresis is used extensively
throughout the world. Most countries
use the same basic methods and most
get similar results (Chia et al, 2011).
See the Quick Set-Up Guide on p16
and Treatment of the Axillae on p18 for
instructions on using the machines.
Figure 2 shows how iontophoresis
works on the sympathetic chain, compared
to other treatments for hyperhidrosis.
Dermatological Nursing, 2012, Vol 11, No 2
CLINICAL SKILLS
Spinal
chord
Sympathetic
chain
Skin
Iontophoresis — stops the
sweat gland cells from
making sweat
Sympathectomy — cutting the
sympathetic nerves
Botulinum toxin blocks the nerve
impulses
Antiperspirants
Figure 2. The effect of iontophoresis on the sympathetic chain compared with other treatments.
Table 1.
Treatment times for use with tap water (STD Pharm, 2012).
Extremities to be
treated
Treatment Time Polarity 1
Treatment Time Polarity 2
Total
Feet only
15 mins
15 mins
30 mins
Hands only
10 mins
10 mins
20 mins
Hands and feet
10 mins
10 mins
20 mins
Axillae
10 mins
10 mins
20 mins
Table 2.
Treatment protocol (STD Pharm, 2012).
First week
Treatment on day 1, day 2 & day
4 (ie,Tues, Wed, Fri)
Second week
Treatment on day 7 & day 10 (ie,
Mon,Thurs)
Third week
Treatment on day 15 (ie,Tues)
Fourth week
Treatment on day 22 (ie,Tues)
This protocol has been used for many
years in UK hospitals. It has been found
to be the most successful of all tap water
iontophoresis protocols to date.
Tables 1 and 2 show the treatment
times and protocol for iontophoresis using
tap water, and Table 3 overleaf shows the
treatment times when Robinul is added,
which is discussed on p12.The treatment
can be carried out in two anatomical areas
simultaneously (Elkhyat, 1993) but it is
recommended that the axillae are treated
separately.
Maintenance sessions need to be
carried out just as soon as the sweating
recurs. For some, this is twice a week
and for others once a month or so. It is
important that the maintenance session is
done as soon as the hands, feet or axillae
become clammy and are not fully sweating
again, otherwise the patient may need to
do the full treatment protocol again.You
need to advise patients that they may not
notice any difference in their sweating until
they have had at least 4 treatment sessions.
Contraindications
Cardiac pacemakers and similar
devices
Metal implants when in flow of current
Pregnancy
Pure water (de-ionised or distilled) is
a bad electrical conductor (18 Mohms) as
it poses a high electrical resistance. Ionised
salt in water makes it capable of conducting
electricity. Generally speaking, all tap water
contains enough minerals to conduct
current, but mineral content in water varies
and it is because of this that we get varying
results with tap water iontophoresis.This is
not fully understood, but it is believed that
if the water is very soft, or a water softener
is used, then the treatment is less effective.
It is not known exactly why
iontophoresis is successful for hyperhidrosis,
but there are various different hypotheses:
1 Electrical current and 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.
2 Iontophoresis 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.
3 Iontophoresis may cause a plug on
the sweat gland or induce an electrical
charge in the gland that disrupts
secretion.
4 Iontophoresis decreases ph in the sweat
duct, which may contribute to eccrine
gland dysfunction.
Direct (DC) or pulsed current (PC)?
Treatment should be given weekly for
4-6 weeks and then continued as required.
It is important to ensure that the current
level is tolerable — iontophoresis should
never be painful. However, the higher the
current, the more successful the treatment.
Use a lower current in the axillae.
Until recently, direct current has been the
current used in most hospitals as these
have been the only machines available.
However, good direct and pulsed current
machines are now available, and many
hospitals are providing a service to
patients with both.
How does iontophoresis work?
Although there is no scientific data on
the subject, direct current is considered
to produce better results for palmar
and plantar hyperhidrosis, providing
the patient is able to tolerate 10mA of
current or more when using tap water.
If they are not able to tolerate this level
comfortably, then pulsed current should
be used, as the tolerance level of this will
be much greater. A patient will be able to
tolerate approximately twice the amount
of pulsed current as they will direct
current.
It is believed that the current is crucial for
the success of the treatment and most
published literature on iontophoresis
focuses on this.Therefore most devices
are current generators, ie the current is
controlled, not the voltage. Skin resistance
is reduced when it becomes wet, so it is
important to have a constant current, no
matter what the resistance is.The current
is responsible for the tingling feeling that
one gets with iontophoresis and is also
responsible for secondary effects.
Dermatological Nursing, 2012, Vol 11, No 2
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CLINICAL SKILLS
Table 3.
Treatment times for use with Robinul 0.05% (St John’s Institute of Dermatology).
Table 4.
Mains or Battery?
Hands
Feet
For Children
Mains
Battery
Treatment 1: 10mA
for 10 minutes
Treatment 1: 10mA for 15 minutes
Treatment 1: 5mA for 5 minutes
Risky?
Most machines are rechargeable
Treatment 2: 12mA
for 10 minutes
Treatment 2: 12mA for 15 minutes
Treatment 2: 7mA for 5 minutes
What if it goes
wrong?
If not, they can use rechargeable
batteries
Treatment 3: 15mA
for 10 minutes
Treatment 3: 15mA for 15 minutes
Treatment 3: 7mA for 7 minutes
Won’t give dangerous shocks
Treatment 4: 17mA
for 10 minutes
Treatment 4: 17mA for 15 minutes
Treatment 4: 10mA for 7 minutes
Has been known
to give out nasty
shocks
Treatment 5: 20mA
for 10 minutes
Treatment 5: 20mA for 15 minutes
Treatment 5: 10mA for 10 minutes
Not
recommended in
electrical storms
Gives similar output as mains
Treating the axillae
For treatment of the axillae, pulsed current
is recommended if it is available. However,
many hospitals still have only direct current
machines and have had success when using
this for their axillae patients. With direct
current, it is recommended that patients
start with a current no higher than 5mA
and increase the current by 2mA each
session.This of course can be much higher
when using a pulsed current machine.The
skin in the axillae is much more sensitive
than in other areas and hence can tolerate
less current.
See page 18 for instructions on
treating the axillae. It is advisable to ask
the patient to bring along their own towel
for this treatment, both to ensure clothes
remain dry and, for most females, modesty
is kept once the bra is removed.
Tap water and Robinul
Iontophoresis for palmar and plantar
hyperhidrosis using just tap water is
successful in about 85% of the population
(Halford et al, 2011) and for the axillae
about 70% (Gambles, 2009).Those who
fail with tap water may be well advised to
use sodium bicarbonate with the tap water
(a teaspoon in each bath of water), as it
is thought — although there have been
no conclusive trials to date — that the
bicarb content of the water can be more
successful than any other element. It is the
salts in the bicarb that increase the efficacy
of the treatment by increasing the salts in
the tap water.This is used widely in many
UK hospitals and is cheap and safe to use.
12
It is well known that iontophoresis
using soft water does not carry such high
success rates as hard water and hence
de-ionised water is not as successful as
tap water. If added bicarb is not successful,
glycopyrronium bromide (Robinul) 0.05%
solution can be used in one bath (the
bath with the red lead) and tap water in
the other bath (Dolianitis et al, 2004). In
this case, the baths are changed over after
each half session, rather than the polarity.
Iontophoresis using Robinul is generally
successful, but can lead to possible sideeffects, such as a very dry mouth, bloating,
constipation, dizziness, drowsiness and
enlarged pupils. It is contraindicated in
those suffering from glaucoma, obstructive
uropathy and gastrointestinal tract and
ulcerative colitis (Badri et al, 2010).
A reduction of Robinul solution to
0.025% can be given if the patient suffers
intolerable side-effects with 0.05%, and
an increase in dose to 0.1% can be given
if necessary. NB: please be sure to inform
your patient’s GP if prescribing Robinul,
otherwise your patient will be unlikely to
obtain a prescription.
For those who are not able to tolerate
the use of iontophoresis with Robinul, then
oral modified-release oxybutynin 10mg
BD — 30mg three times a day should be
considered.
If your Trust only carries out one
course of treatments for patients, ensure
that the patient knows this at the time of
consultation so that they can be prepared
Dermatological Nursing, 2012, Vol 11, No 2
to buy their own machine for home use
when the 7 treatment sessions reach a
conclusion.
Frequently asked questions
Q Why not design an iontophoresis machine with
automatic polarity?
A Because the results are not as good.
Sufferers of hyperhidrosis tolerate the
passage of iontophoresis current differently.
During the first phase, the current
tolerated may only be a few milliamps
(mA), while for others it may be the
maximum intensity. During the second
phase (after changing the polarity), the
intensity applied will not necessarily be
the same. It must be possible to make
adjustments at any time to avoid pain or
burning. An automatic system will never be
able to deliver these adjustments.
Some people will have strong and
sometimes unpleasant sensations at low
current levels, while others will feel virtually
nothing. What is important is the quantity
of the current passing. For an adult, an ideal
treatment current should be between 15
and 20mA using a direct current, but this
is not tolerable for some and good results
can still be obtained at much lower current
levels for many.
Q Is it risky to exceed the recommended treatment time?
A No.There is no major risk and it can,
in stubborn cases, be advantageous to
increase the treatment time on occasions.
20 minutes of treatment time is the
average guide and we recommend this
initially.
CLINICAL SKILLS
Q How much water should be put in the
trays?
A The water only serves to
conduct the current, so not
too much; just enough to cover
the area of sweating. Each
machine comes with its own
recommended level.
Q What temperature should the water be?
A Warm-hot water, but not so
hot it will burn.
Q If the skin goes red above the water level, is
there a risk of burning?
A This redness is due to the
vasodilation of the skin blood
vessels. It is quite common and is
of no consequence. If it becomes
troublesome, put a thin layer of
petroleum jelly, such as Vaseline,
on the wrist line or just above the
water level on the feet and apply
a mild hydrocortisone cream or
similar to the affected area posttreatment.
Q What if a treatment session is missed?
A Carry out the treatment
session the following day
and continue the protocol. If
treatment has not been carried
out for a week or more, start
the protocol again. Encourage
patients to bring their diaries to
the first consultation, so they can
ensure they are available for all
treatments.
Dermatological Nursing, 2012, Vol 11, No 2
Declaration of interest
The author is employed by STD
Pharmaceuticals to undertake
iontophoresis training in hospitals
throughout the UK. DN
References
Badri H, Coyne PE, Bhattacharya V
(2010) Update on the management of
hyperhidrosis. Mims, 16 Dec 2010
Chia HY, Tan AS, Chong WS, Tey
HL (2011) Efficacy of iontophoresis
with glycopyrronium bromide
for treatment of primary palmar
hyperhidrosis. J Eur Acad Dermatol
Venereol. Aug 3. doi: 10.1111/j.14683083.2011.04197.x
Davies K, Lawton N (2009) An
alternative treatment option for
compensatory hyperhidrosis after
endoscopic thoracic sympathectomy.
Clin Exp Dermatol 35(1): 105-10
Dolianitis C, Scarff CE, Kelly J,
Sinclair R (2004) Iontophoresis with
glycopyrrolate for the treatment of
palmoplantar hyperhidrosis. Australas
J Dermatol 45(4): 208-212
Further information and leaflets for patients are
available from Julie Halford at the Hyperhidrosis
Support Group: www.hyperhidrosisuk.org
Elkhyat A, Agache P (1993)
Treatment of hyperhidrosis by
iontophoresis of weakly mineralised
water. Cutaneous Biophysics Lab,
Dept of Functional Dermatology,
Besancon, France
Conclusion
Gambles B (2007) Poster presented at
the 2007 BDNG Conference
Iontophoresis is widely used
throughout the UK and is
considered a safe and successful
treatment for primary
hyperhidrosis of the hands, feet
and axillae whether carried out
in a hospital setting or at home.
Despite its regular and effective
use, there is very little scientific
data on the subject. Mineral
content of water has an impact
on the success of the treatment,
with hard tap water being most
effective. However, because of
14
the varying mineral content in
tap water across the regions,
varying results are achieved in
tap water iontophoresis. Direct
current is considered to get
the best results for palmar and
planter hyperhidrosis, while pulsed
current is recommended for the
treatment of the axillae.
Halford J (2011) Hyperhidrosis —
sweaty feet: cause, treatment and
maintenance. Podiatry Rev 68(6): 4-5
Halford J, Hunt L, Millington G
(2009) Hyperhidrosis. BMJ 338:
942-944
Halford J (2009) Managing
hyperhidrosis. Indep Nurse Sept 7,
2009
Lowe NJ, Cliff S, Halford J, et al
(2003) Guidelines for the primary
care treatment and referral of focal
hyperhidrosis. eGuidelines 19(Feb):
373-377
CLINICAL SKILLS
Iontophoresis Quick Set-Up Guide
Idrostar Pro Pulse, Idrostar Pro, Iomax 4, i2ma & Idrostar machines
Place machine on table, with hand baths in front or foot baths on floor, or insert
axillae electrodes into pads.
Insert leads into the corresponding colour sockets on left side of the machine
(both sides if treating hands and feet).
Place metal electrodes into baths with upturned corner in upper left quadrant of
the baths.
Place acrylic grills on top of metal electrodes.
Attach the remote controls to the metal electrodes, ensuring that the acrylic
grills are fixed in position. (If treating hands only, feet only or axillae only, use the
remotes on the left-hand bath only and plug red lead into left bath and black lead
into right bath. If treating hands and feet together, use remotes and leads in both
baths, with red leads in hand baths and black leads in foot baths.) Idrostar Pro
Pulse, Idrostar Pro & Iomax 4 only.
Put approximately 200ml of tap water into each hand bath or 300ml into each
foot bath (depending on machine used), or thoroughly soak axillae pads.
Turn on the machine and, after ensuring that all jewellery and body piercings have
been removed, place hands or/and feet in baths, ensuring the palms and soles
are pressing lightly on the acrylic grills and are not touching the metal plates (see
image, left), or place rubber electrodes into the axillae and, by using either the
remote controls for the hands, or the up/down arrows, or dial (i2ma & Idrostar)
on the machine for the feet & the axillae, increase the power.
Increase the current to a level which is tolerable. A feeling of tingling or a pins and
needles sensation should be felt, but this should not be uncomfortable. Maximum
20mA (DC) for hands and feet and 5mA (DC) initially for the axillae; increasing
by 2mA at each session if not uncomfortable. We recommend lower levels for
children — up to 15mA (DC) maximum. These levels can be doubled when
using a pulsed machine.
Ensure hands or feet are kept in the baths at all times when the current is on.
After 10 minutes (15 minutes when treating feet only), turn down the current so
no current is registering (0mA). When treating the axillae, re-soak the pads at this
stage.
Change the polarity by depressing the normal/reverse or polarity button on the
left-hand side of the machine, or both sides if treating hands and feet.
Turn up power on machine again and increase level of current to a tolerable level
as before.
After 10 (or 15 minutes when treating feet only), turn down current and turn
machine off.
Empty baths of water and thoroughly wash and dry all parts using detergent or
similar cleaner.
Do not use alcohol on the machine.
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CLINICAL SKILLS
TREATMENT OF THE AXILLAE
Iontophoresis axillae pads — for the treatment of hyperhidrosis of the axillae
Only to be used in conjunction with the following iontophoresis machines: Idrostar and Idrostar +; Iomax 4; I2ma; Idrostar Pro/Pulse
1
1 Insert the sponge pads over the rubber electrodes (Figure 1).
2 The leads on the rubber electrodes attach directly to the electrode cables, by
pushing the socket and plug together as shown in the picture above (Figure 2).
Do not use the crocodile clips as these are only used for treatment of the hands
and feet.
2
3 Soak the sponge pads again in water and insert into axillae, ensuring a good fit
(Figures 3 and 4). If preferred, several wet gauze swabs can be placed on top of
the pad to ensure a tighter fit.
4 Once the pads are in place, turn the power up to a comfortable tolerance level,
but not initially above 5mA (DC). CAN BE MORE WHEN USING PULSED
MACHINE.
3
5 Maintain this power level for 10 minutes. Reduce power to zero and turn
machine off. Change polarity of machine by clicking the inverter switch from 1
to 2 if using the Idrostar (Figure 5), or change leads if using the Idrostar +, soak
sponge pads again, insert into armpits and increase power again for a further 10
minutes. Reduce power to zero and turn machine off.
6 Treat 7 times over a 4-week period as per hand and feet iontophoresis treatment
protocol. The power should be increased by 2mA per session if tolerated by the
patient.
Ensure that the sponge pad is as wet as possible and remains so during
treatment, as the treatment will be more successful if this is done.
The rubber electrode should not come in direct contact with the skin during
treatment.
4
The sponge can be hand-washed after use, but should only be used on one
user of the machine.
Before use, remove bra, body piercings & all jewellery below the neck. Rinse the
pads with tap water, ensuring that the pads are thoroughly soaked.
5
The pictures show the pad slightly sticking out of axillae.This is to show folding of
the pads, but when in correct position they are barely visible.
Sometimes irritation can arise around the axillae after using iontophoresis. If this
becomes a problem, hydrocortisone cream 1% can be helpful and should be used
immediately after treatment.
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