Dry is Beautiful: MiraDry w/ Dr. Carolyn Jacob

Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator and technology innovator. The title of today's episode is "Dry is Beautiful." Dr. Bass, I'm not sure what we're doing here. Usually we're talking about working on a body part or about a particular technique. What is the focus of today's episode?

Dr. Lawrence Bass (00:36):
You're right, Summer, here we're talking about something that's not strictly speaking about appearance, but definitely relates to how others perceive us. Many things about modern life tend to amplify the differences for people with excess sweating medically, what we call hyperhidrosis with frequent washing antiperspirant and our climate controlled modern lives. Most of us don't think a lot about sweating, but for those with hyperhidrosis, this can still be a devastating social problem on a daily basis. And given the aseptic outlook of modern Western life can even be a concern for many who sweat in a normal fashion.

Summer Hardy (01:20):
Before we get to modern options, can you give me my history lesson for the day?

Dr. Lawrence Bass (01:25):
Sure. So for people with milder sweating issues, treatments with aluminum chloride went under the brand name Drysol were commonly used, and this would create treatment for a period of time that would be repeated a few times a year. There were also oral medicines that block the cholinergic stimulation that brings on sweating. And for patients with severe problems with hyperhidrosis, they would actually have the sympathetic branches of the nerves cut surgically or even occasionally have the sweating area of skin excised and then skin graft. And that obviously was a big procedure that created a lot of scar. So these are historical things, not really part of our modern discussion of hyperhidrosis.

Summer Hardy (02:23):
Okay, thanks for explaining. So what about today in 2024? What are the main options?

Dr. Lawrence Bass (02:29):
Well, I brought an expert to bring us up to date on the latest in this area. Dr. Carolyn Jacob is a board certified dermatologist who's an associate clinical professor at Northwestern's Feinberg School of Medicine. She's the founder and medical director of Chicago Cosmetic Surgery in dermatology in Chicago River North Neighborhood. After her dermatology training, she completed the cosmetic and laser surgery fellowship at Harvard Medical Skincare Physicians. And for the listeners, this is really the pinnacle cosmetic and laser fellowship in the United States. She's performed research and lectured and discussed in the media many cutting edge treatments in cosmetic medicine, including excessive sweat reduction with MiraDry technology, cellular treatments, injectable aesthetics, body shaping with high frequency electromagnetic energy, what's called HIFEM, and with radio frequency, which is in a combined device, EmSculpt Neo as well as many others. So Dr. Jacob, welcome.

Summer Hardy (03:40):
Thanks for having me. Hi, Dr. Jacob. Thank you for joining us today as an expert. Can you tell us a little more about the biology of sweat, how it's made and different kinds of sweat?

Dr. Carolyn Jacob (03:51):
Absolutely. So there's these main sweat glands on your skin, which are known as eccrine glands. They also sit adjacent to these other glands called arine glands, but the eccrine glands are the ones that create the actual watery sweat that you notice when you're working out or when you're nervous. And these glands tend to be more concentrated in the underarm area and the palms and the soles.

Summer Hardy (04:13):
Okay. Okay, that makes sense. Could you talk more about hyperhidrosis in terms of how it manifests, where in the body it occurs, and how it impacts patients?

Dr. Carolyn Jacob (04:22):
Sure. So more than 4% of the population is affected by what we call primary axillary hyperhidrosis, which is excessive sweating beyond normal physiological needs. This is also a condition that usually has been present for more than six months. It might run in your family as well, and it inhibits you from some of your daily activities because of your need to either wear black clothes all the time so people can't see that you're sweating or to shower frequently. And then there's other issues such as odor, which it can be offensive or bothersome to yourself as well. Some people will sweat in a color, which is called chrome hydrosis, and then also you can get different skin conditions such as eczema and intertrigo in areas that are moist and damp often. So it causes a lot of problems besides just embarrassment.

Summer Hardy (05:09):
Got it. Wow, that's much more than I ever thought about. So then what are the big options today for patients with hyperhidrosis?

Dr. Carolyn Jacob (05:17):
Well, luckily today we have a lot of treatments for hyperhidrosis, and again, some of our patients don't come in with just the underarms. They'll also have hands. As Dr. Bass had already mentioned, back in the old days we had mostly topical products containing aluminum chloride. But the problem with those is that they led to irritation, redness, and sometimes eczema in the treated area. Fast forward, those have advanced to a particular product that's called glycopyrronium tosylate. This is a prescription called QBREXZA that you can use just on the affected areas of the underarm. Some people will use it off-label for the hands and feet, it's a wipe, it just lasts for about 12 hours and then you throw it away after you've applied it to the area. Other treatments that exist, also brand new, something called Brella, which uses this sodium patch to actually activate and heat up a little bit of the eccrine ducts. So the sweat glands called eccrine glands have a little tube that allows the sweat to get to the skin and it kind of stuns those tubes and the eccrine glands so that you don't sweat for several months. And that's just an in-office treatment where a patch is applied. But for people who really want to stop their sweating permanently, there's microwave technology known as MiraDry.

Summer Hardy (06:29):
Okay. All of those sound really interesting. What are some of the benefits and cons of some of those options just in general terms?

Dr. Carolyn Jacob (06:37):
Sure. So again, if you're talking about just underarm sweating, then the go-to decreasing sweat permanently treatment would be the MiraDry microwave technology. It works beautifully in that it's an in-office procedure that takes about an hour. The area is numbed up and then the treatment is performed. Microwaves just like your microwave in your house can heat up water and that helps to destroy those little sweat glands just in the area that's being treated. Whereas the rest of your sweat glands will continue to sweat normally and you won't have any issues such as sweating excessively somewhere else. That has been found to occur in that other treatment that Dr. Bass had mentioned, which was the one where they actually cut the nerve. So we never recommend that for patients anymore. I failed to also mention that they're all oral treatments. There's pills that you can take for excessive sweating. So if you're a sufferer who has both your hands, your feet, your underarms, your face, you may be a better candidate for taking some of these pills under the direction of your dermatologist.

Dr. Lawrence Bass (07:42):
So while we're talking about pluses and minuses, just add in there, Dr. Jacob, the pluses and minuses of something like Botox injection, which is also cleared for hyperhidrosis compared to something like MiraDry.

Dr. Carolyn Jacob (07:57):
Sure, absolutely. So there's other treatments that can be done locally for focal hyperhidrosis in the underarm such as Botox or botulinum toxin injections. These injections are performed in a physician's office with a little bit of topical anesthetic and they're very comfortable to have done, but they are temporary studies show that Botox brand lasts about 260 days on average in reducing the sweat, but it does have to be done in a repeated fashion. In some states that treatment can be covered by insurance, but in other cases it's not covered by insurance. So it gets a little tricky to do a repeat treatment that's going to be expensive over and over again, but that is another option for treating excessive sweating.

Summer Hardy (08:40):
Thanks for sharing all of that. You mentioned a permanent solution with MiraDry, and you touched on it a bit, but can you tell me a bit more how does it work?

Dr. Carolyn Jacob (08:50):
Absolutely. So this technology has been around since 2011. Lots of treatments have been done successfully and that's what makes it such a great treatment in that it permanently reduces the sweat after two simple treatments. The treatments are separated by two months. So you'll come into the office, we'll mark out the areas to be treated. A little tiny kind of fake tattoo is put onto the area. The area is numbed up with some local anesthetic, and that takes just a few minutes to do. And then once it's numb, the applicator of the MiraDry device is put onto the skin and little tiny rectangles of tissue are treated at a time to heat up the skin. Their device cools the top layer of skin, so there isn't any issue with the actual skin itself. And that energy of heat from the microwave is put down into those sweat releasing glands that we call the rine glands that then permanently reduces them.

(09:45):
With one treatment you get about a 69% reduction with two treatments, it's about an 89 or greater percent reduction in sweat that is then permanent. The reason it's permanent is you don't regenerate these eccrine sweat glands. So the ones that you have are the ones that you're born with, and if we get rid of them in the underarm area, then you don't have to worry about them again. But remember that you'll sweat normally everywhere else. And for these sufferers, they do sweat normally in a lot of other places, but sometimes it's just the underarms are profusely sweating.

Summer Hardy (10:15):
This sounds like an interesting approach for combating hyperhidrosis. What does the data show about the results?

Dr. Carolyn Jacob (10:22):
The results are great. As I mentioned in the first trial that was done back in 2010, published in 2011, they showed that the results decreased sweating by about 69%. They then added a second treatment, did another study, and found out that there was an 89% reduction overall of the amount of sweat for these patients who suffer from underarm sweating. That's a really good permanent amount. They did biopsies to show you that there's no more of the sweat glands in the area. And so a few little areas might get skipped because as I mentioned, you're doing little tiny rectangles of treatment in the entire underarm area. So if someone does have sweating, we have them come back. We'll do what's called a star iodine test. We'll find out where those areas are that they might be sweating from and have a conversation as to whether or not they need a third treatment. But the majority of patients get two treatments done two months apart. There's about two days of having a little bit of swelling under your arms, and so we ask people to ice the area, take some ibuprofen and take it easy for a couple of days.

Summer Hardy (11:22):
Okay, great. Thanks for walking through that. So how is microwave energy different and what makes it well suited for MiraDry?

Dr. Carolyn Jacob (11:32):
Sure. So patients with hyperhidrosis can sweat excessively while they're sitting still. It usually doesn't occur until puberty. And then after that it becomes a bigger problem. The patients are suffering so badly, they may have to wear pads under their arms, et cetera. What happens with microwave technology is microwave energy is very specific for water as to fat or skin or muscle tissue. So specifically microwave technology has only been used in the medical field for treating things that deal with water such as tate enlargement. They've used microwave technology to decrease the size of the prostate nonsurgically from that technology. They then developed using this for the underarm sweating. So microwave technology is still the number one permanent treatment for treating underarm sweating, and we're really excited that we have the ability to offer this for our patients.

Summer Hardy (12:29):
Okay, great. And I know you also touched on this before, but you mentioned for recovery you might have to ice the area and there might be swelling. Is there anything else I should know if I want to go for a treatment?

Dr. Carolyn Jacob (12:40):
You would need to shave the area two days prior, and this includes men as well. When you have the treatment done, the collateral damage from the heat sometimes reduces a little bit of the hair in the area. One recent study showed that it decreased the hair by 72%, and it doesn't matter what color the hair is because the microwave technology is just using heat. It's not being absorbed by a particular color repair. So far, I've never had a single man be upset that he has less underarm hair after the series of the MiraDry treatments, but then we need to have you ice it and take a little ibuprofen. There can be some swelling because we have used this device to create heat. We tell people to kind of refrain from big physical activities like beach volleyball and those sort of things for a couple of days.

(13:28):
I haven't had a patient call me in years with any issues of side effects after the treatment. But during the healing phase, there's no changes on the surface of the skin. Everything's happening underneath the skin. But sometimes because of that heat, you can get a little bit of bumps that you can feel under the skin and those bumps go away with time or with some treatments that we'll do in the office, such as a little shockwave treatment or a little injection with a mild steroid like we would do for an acne pimple. So those occasionally happen, but they're very easily resolved with some treatments and with time.

Dr. Lawrence Bass (14:04):
We started this discussion with a focus on hyperhidrosis, but that's only part of the target audience that can benefit from this technology. What other groups of people do you see coming in for treatment?

Dr. Carolyn Jacob (14:18):
Well, there are a lot of patients like me who are perfectly normal throughout the day until they have to get up on podium and give a lecture and then they start sweating. So people that have to give performances, people that have to be in big audiences to give lectures and talks, sometimes that creates this situational sweating for them. And that's really problematic, especially if you haven't remembered to wear a dark outfit because your sweat will show when you're in front of everyone. So the situational sweaters also can benefit very greatly from having miry treatments. And we have some people who just don't want the sweat in their underarms at all. Again, remember you're going to sweat normally everywhere else, but this will reduce the amount of sweat by about 89% in the underarm. So there's a lot of people that can enjoy improvement from the MiraDry treatment.

Dr. Lawrence Bass (15:09):
Yeah, I mean that's a huge reduction in sweating just in daily life. I know you've been an active researcher in this area. We like to have people like you on the podcast who can speak authoritatively about a subject and know all the ins and outs because of that extensive experience with it. Tell us a little bit about what you found in your research.

Dr. Carolyn Jacob (15:32):
Some of the research that we conducted years ago was basically patient satisfaction because again, this was a condition that didn't have a really great treatment for it. People don't want to take pills every day. They don't want to have to use solutions every day. And when we looked at the patients that were treated, the satisfaction level was above 95% for these patients. The comments we got from patients were things such as life changing, saved my life, saving me time and energy, saving me time and money because they're not ruining clothes, they don't have to change clothes frequently. They don't have to take extra showers. So very overwhelmingly pleased patients, which makes it a great treatment for us to get to do for patients as well. Now moving into the future, we're actually looking at some other applications with the device. It is a little tricky in that the device has a disposable tip that's used for each individual person that has to vacuum up the skin a little bit away from the underlying structure.

(16:30):
And because of that, we cannot use this treatment tip on the hand. However, we've known that there's been lots of patients who've suffered with sweating on the chest and on the back. And this also causes great concern and stress for the patients. So we will be doing a study in the near future, testing it for the usage on the chest and on the back in different patches to reduce excessive sweating in those areas, which will bring great relief to those patients. And as aside, we actually have done this to patients off-label already. We know that it works, but it's now time for us to actually put it to the test and do a rigorous study on it.

Dr. Lawrence Bass (17:07):
So this is really a huge thing. And so much of what we do in aesthetic medicine is about appearance. As I said at the beginning, this is not appearance, but it has to do with convenience, lifestyle, your ability to do work, your ability to interact with people socially, and to have the confidence to know you're going to be able to do that. And that confidence lets you project your personality instead of your anxieties about the problem of sweating or some feature of appearance. And that's really everything that we do every day in aesthetic medicine.

Dr. Carolyn Jacob (17:44):
Yeah, absolutely. And I think that's the feedback we get from patients is that, oh my, there's a way to potentially cure this problem permanently, and that's what they really want, because if you're sweat bothered or if you have excessive sweating, it's a home run treatment for these patients.

Summer Hardy (18:02):
Before we end this podcast, Dr. Jacob, can you share some takeaways with our listeners?

Dr. Carolyn Jacob (18:07):
Sure. So don't suffer in silence. Dermatologists are the doctors of sweat. Not everybody knew that. Raise your hand if you have trouble sweating because we've lots of different ways that we can help you treat you and make you not embarrassed, make you not feel stressed about the condition that you have. And with MiraDry microwave treatment, we can permanently reduce your underarm sweating and give you a life that's so much easier to lead.

Summer Hardy (18:34):
Great. Thank you. And what are your takeaways, Dr. Bass?

Dr. Lawrence Bass (18:37):
So as I said, everything that affects how we feel about ourselves is part of how we project to friends, family, and outsiders part of our image, and therefore it's part of beauty. The durable response of sweat glands to energy-based destruction makes it a particularly appealing approach that has that benefit of permanence that most of the other treatments cannot offer. Reducing sweat production minimizes dampness and also odor. And so it's an important part of hygiene and daily maintenance for hyperhidrosis patients. Other areas are still unsolved problems. Some of them may be addressable this way, as Dr. Jacob pointed out on the torso. But areas like the palms are perennial problem areas that we're still a little bit frustrated with. And as you also heard, occasionally there's rebound in other areas with increased sweating with certain constant treatments. But overall, anything that reduces your concerns about how others perceive you is a plus towards improving your life. And this is a perfect example of that. I'd like to thank Dr. Jacob for joining us today and sharing her research and perspective in this sometimes overlooked area.

Dr. Carolyn Jacob (20:00):
Thanks so much for having me. I appreciate it.

Summer Hardy (20:03):
Thank you, Dr. Jacob for opening up our understanding of this horizon in self-care.

Dr. Carolyn Jacob (20:08):
You're very welcome.

Summer Hardy (20:10):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at podcast@drbass.net or DM us on Instagram @drbassnyc.