What is hyperhidrosis?
Hyperhidrosis is a disease characterized by excessive sweating, even when it is not hot or the person is lying down. It affects various parts of the body. Its causes may have a genetic or pathological origin.
The diagnosis is made through blood tests, urine and / or specific tests. The treatment can be medicated, surgical or through specific procedures performed in the doctor’s office.
Possible complications include mycosis, diaper rash and infections.
In the ICD-10 index (International Classification of Diseases), hyperhidrosis corresponds to the code R61.0.
Sweat is a body mechanism to preserve body temperature – which, in normal situations, should be around 36ºC. Thus, the organism can perform its vital functions properly.
For sweat to occur, it is necessary for the brain to send stimulating orders to structures spread throughout the body, called sweat glands.
The glands, in turn, conduct sweat through ducts located on the outer area of the skin, causing the liquid to cool the body.
Sweat is made up of water, mineral salts and some natural chemical compounds. Therefore, it does not smell originally. The odor we associate with it is the result of a chemical reaction between the liquid and some bacteria that are located on the skin.
There are two types of hyperhidrosis, which are defined according to the source of the problem. Are they:
Primary hyperhidrosis is genetic, that is, usually, the individual has at least one other person in the family who presents the problem.
This type of hyperhidrosis begins to manifest itself during childhood or, at most, during the early years of adolescence. The most affected areas are the hands, feet, armpits and face.
The episodes usually happen mainly during the day. Manifestations of primary hyperhidrosis at night are rare.
According to data from the World Health Organization (WHO), it is estimated that somewhere between 2% and 3% of the world population suffers from primary hyperhidrosis. Most of these people, however, do not seek medical advice.
Secondary hyperhidrosis is acquired throughout life, as a direct consequence of some causative agent that is causing the problem.
The most common causes of secondary hyperhidrosis are health problems or a side effect of a medication. The disease can also be caused by natural phenomena – such as menopause, for example.
This type of hyperhidrosis can affect any part of the body, at any time of the day, including at night.
In addition, secondary hyperhidrosis can affect people of all ages. However, it is more common in adult individuals.
Classification by affected areas
It is also possible to classify hyperhidrosis as focal , when it affects only one area of the body, or as generalized , when it affects the whole body.
The main cause of hyperhidrosis is a kind of sweat gland hyperactivity. This means that some phenomenon is over-stimulating these structures.
The reasons for this hyperactivity can be:
According to a survey by the American institution Center of Hyperhidrosis, about 50% of cases of hyperhidrosis are classified as primary hyperhidrosis – that is, the disease has a hereditary origin in half of the patients.
Thus, the genetic tendency is the main cause of hyperhidrosis. The scientific community is not yet sure how the heredity factor for the disease works, but Chinese researchers have already managed to map the gene responsible for the phenomenon.
With research advancing, it is possible that, in some decades, there will be more efficient treatments for hyperhidrosis of family origin.
According to data from the gynecology department of the Scottish hospital Dumfries and Galloway Royal Infirmary , it is estimated that about 85% of menopausal women suffer from secondary hyperhidrosis.
The phenomenon happens because, during menopause, there is a drastic drop in the levels of the hormone estrogen, which is produced by the uterus.
Estrogen is one of the main female hormones, responsible for, among other functions, regulating body temperature. This process directly affects the amount of sweat produced by the body.
The episodes of hyperhidrosis caused by menopause can happen 20 to 30 times a day, on average, and tend to be more intense at night.
Hyperhidrosis and anxiety disorders are closely related and work in a kind of vicious circle.
Anxiety attacks can affect various parts of the body, including a region of the brain called the hypothalamus, which in turn interferes with the stimulation of sweat glands.
These glands are responsible for releasing perspiration. Therefore, it is common for anxious people to develop secondary hyperhidrosis during their lifetime.
The problem is that hyperhidrosis attacks end up causing even more anxiety in having this type of disorder.
In other words: anxiety causes hyperhidrosis, which causes more anxiety, which causes hyperhidrosis, and so on.
Diseases that affect the nervous system
Within the central nervous system, there is a kind of special sub-department called the sympathetic nervous system (also known by the acronym, SNS).
The sympathetic nervous system is responsible for the body’s reactions to situations of stress . It is thanks to the work of the NHS that human beings are capable of instinctive actions when they are exposed to dangers – such as throwing a punch at an aggressor, fleeing an attempted assault or starting an argument with someone, for example.
In addition, the sympathetic nervous system is also capable of stimulating another very common reaction to stress: sweat.
Therefore, some diseases that affect the nervous system can interfere with the work of the NHS, and end up causing a secondary hyperhidrosis.
Problems that can cause hyperhidrosis include:
- Alzheimer’s disease;
- Parkinson’s disease;
- Huntington’s disease;
- Multiple sclerosis;
- Migraines, in rarer cases.
Diseases that affect the functioning capabilities of the heart can generate an overload of the sympathetic nervous system, which needs to react to the stress situation caused by the imbalance in the cardiorespiratory system.
This overload causes the nervous system to react in a much more intense way than normal, generating phenomena such as dry mouth, anxiety attacks and, of course, hyperhidrosis.
Heart diseases that can cause hyperhidrosis include:
- Cardiac insufficiency;
- Aortic insufficiency;
- Myocardial infarction.
Glycemia is the clinical name for the amount of sugar concentrated in the blood. When this rate is lower than normal, we say that the person is suffering from hypoglycemia .
The phenomenon of hypoglycemia is relatively common in patients with diabetes, but it can affect anyone in specific situations – such as spending a lot of time without eating, being malnourished or taking medicine to lose weight, for example.
The body’s response to low blood sugar comes through the adrenal (or adrenal) glands, which are just above the kidneys. These structures release a very famous hormone called adrenaline.
Adrenaline, in turn, has the function of regulating blood pressure and heart rate. The problem is that, during this process, this hormone also causes symptoms very similar to those of an anxiety attack – hyperhidrosis among them.
The fat acts as a layer of thermal insulator, which causes the body to retain heat. As sweat is a thermoregulatory mechanism, it is natural for obese people to sweat more.
Hypoglycemia is a phenomenon that occurs more easily in individuals with diabetes. Consequently, diabetics end up being a population with a greater predisposition to develop hyperhidrosis.
There is, at the base of the skull, a tiny gland called the pituitary gland. The function of this structure is to produce and release several important hormones for various parts of the body.
One of these hormones produced by the pituitary gland is called GH, and it is responsible for the growth of the individual during childhood, adolescence and early adulthood.
Acromegaly is the name given to a disease characterized by the excessive production of GH, especially during adulthood. The phenomenon causes the affected person’s feet, hands and cartilage to enlarge and become deformed.
As the problem directly affects the pituitary gland, the consequences of acromegaly extend to various parts of the body. One of these developments is the development of secondary hyperhidrosis.
The thyroid is one of the most important glands in the body and is located in the neck. It is responsible for releasing hormones that significantly affect the functioning of organs such as the brain, heart, lung, kidneys and uterus, among others.
When the thyroid produces more hormones than it should, a problem called hyperthyroidism is established .
Because of the importance of the thyroid, the excess of hormones released by it speeds up the chemical processes in various parts of the body, causing imbalances – among them, hyperhidrosis.
Hyperhidrosis can also manifest itself as a side effect of certain medications. Among the drugs that can cause the problem are antihypertensive drugs, antipsychotics, antidepressants, certain vitamin supplements and some antibiotics .
If you are experiencing episodes of hyperhidrosis and suspect that the reason may be some medication, it is worth reading the package insert carefully and discussing the matter with the doctor who prescribed it.
The use of drugs such as ecstasy, methamphetamine and PCP (which, in fact, goes by the name of phencyclidine) can induce hyperhidrosis.
Hyperhidrosis is one of the main symptoms of a disease called gout (also known as gouty arthritis ). The problem is characterized by inflammation of several joints, caused by the accumulation of uric acid in the bloodstream.
Generally, in cases of gout, the parts of the body affected by excessive sweating also hurt and acquire a reddish color.
Cancers and tumors
It is not yet known exactly why some types of cancer and tumors cause hyperhidrosis. Some studies suggest the possibility that excessive sweating is the result of the body’s efforts to fight cancer, but this information still inhabits the field of hypotheses.
The fact is, yes, certain types of cancer can cause hyperhidrosis. Some of them are:
- Liver cancer;
- Bone cancer;
- Mesothelioma, a type of cancer that affects the tissue that lines organs like the heart, lungs and stomach;
- Carcinoid tumors, which usually reach the digestive system;
- Hodgkin’s lymphoma, which affects the lymphatic system.
There are records of cases of hyperhidrosis at any age, from babies to the elderly. According to data from Cedars-Sinai Medical Center , a hospital located in Los Angeles, it is estimated that somewhere between 1% and 2% of the adult population of the United States has or will develop hyperhidrosis throughout life.
Some characteristics that can make an individual more susceptible to developing the problem are:
- Family history of hyperhidrosis;
- Diseases that affect the nervous system;
- Thyroid dysfunctions;
- Cardiovascular problems;
- Drug’s use.
Hyperhidrosis is a condition characterized by a single symptom: excessive sweating.
It can be tricky to measure how much you sweat too much. In general, it is normal for human beings to sweat in certain contexts and situations – when it is hot, during physical exercises or in situations of stress and / or nervousness, for example.
The sweat that characterizes hyperhidrosis is, in general, abundant, to the point of disturbing the patient’s quality of life and self – esteem . It usually happens at any time of the day, without any activity or situation that may motivate perspiration.
There is no fixed guideline on what it would be like to sweat too much – no tabulated level or universal standard. In general, excessive sweating is one that causes the patient so much shame to prevent him from doing any activity, such as doing a physical exercise, greeting someone with a handshake, giving a hug, driving or using the computer keyboard , for example.
The parts of the body that are most often affected by episodes of hyperhidrosis are the hands, feet, face and head. However, sweat can appear anywhere.
It is common for patients with hyperhidrosis to suffer from at least one weekly crisis of the problem.
When can hyperhidrosis mean an emergency?
In some cases, excessive sweating can be a symptom of a medical emergency that requires immediate treatment.
Look for a hospital as soon as possible if, in addition to excessive sweating, you experience any of the following symptoms:
- Fever above 39ºC;
- Feeling of imminent fainting;
- Mental confusion;
- Chest pain.
Hyperhidrosis Trigger Syndrome
Hyperhidrosis Trigger Syndrome is a common phenomenon among patients suffering from the problem.
Basically, sweating excessively makes patients so nervous that they experience symptoms of anxiety. Anxiety, in turn, only further intensifies hyperhidrosis, creating an endless drama during the crisis.
People who are suffering from Hyperhidrosis Trigger Syndrome usually experience some of the following symptoms every time they start to sweat:
- Tingling in the hands;
- Difficulty breathing;
- Sensation that the heart is beating more slowly or faster than normal;
- Pulsation in the ears;
- Stomach and / or stomach pain;
- Tension in the neck and shoulders;
- Feeling of fear and / or panic;
To diagnose hyperhidrosis, the most recommended professional, at first, a general practitioner . The doctor should assess the suspicions about the origin of the hyperhidrosis and, only then, refer the patient to a specialist.
The specialist, in turn, can be a dermatologist , neurologist or cardiologist , according to the cause of hyperhidrosis.
During the first visit, the doctor will likely ask you some questions about the patient’s symptoms and medical history, and then will order some tests and tests to arrive at an accurate diagnosis.
Some of the exams that can be ordered are described below:
Blood tests are done to assess whether hyperhidrosis may be caused by a specific health condition – such as diabetes or hypoglycemia, for example.
As in the case of blood tests, urine tests are requested by the doctor to assess whether any health problems are causing hyperhidrosis.
Urine tests are done mainly to rule out that the cause of excessive sweating is some dysfunction in the thyroid.
The iodine test (also known as the starch-iodine test) is one of the most used tests to diagnose hyperhidrosis.
It is done by applying iodine tincture to the places most affected by sweat. After a while, a small amount of starch is sprinkled on the spot. The reaction of the two substances will leave the areas affected by hyperhidrosis covered by a dark blue color.
The test consists of placing a specific role to perform the exam on the area that is usually most affected by sweat during hyperhidrosis.
After some time, the paper is removed and weighed on a special scale to check how much sweat has been concentrated there.
Yes, hyperhidrosis can be cured .
Secondary hyperhidrosis usually disappears once the disease causing the problem is treated.
Primary hyperhidrosis, on the other hand, can be treated through some specific procedures or surgeries.
The treatment for hyperhidrosis can be surgical, with medications or involve some specific procedures that are applied in sessions.
Long-term procedures are treatments known to be common in the aesthetic field. They usually show results after a few weeks or months and need to be redone from time to time.
Iontophoresis is a procedure of using electrical impulses to increase the absorption of sweat by the skin through stimuli.
For this, two electrodes are used – a kind of conductor of electric currents made of steel. Both are connected to the region to be treated.
One of the electrodes is responsible for charging positive charges, while the other emits negative electrical charges. Combined, these two types of chain can overcome the skin barrier.
Once the current enters the skin, it will be able to form a kind of electrical barrier, which, in turn, will be responsible for removing sweat molecules.
Iontophoresis is applied in sessions, which last, on average, from 15 to 20 minutes. It is recommended that patients with hyperhidrosis do 5 to 20 consecutive days of treatment, depending on the severity of the case.
After this period, the expectation is that the moisture levels of the skin are already close to normal. Thereafter, the team responsible for the case will recommend the frequency of treatment maintenance sessions, which usually happen once or twice a week, for periods that can last for months.
Known for its role in aesthetic procedures, Botox is a very popular treatment option for hyperhidrosis.
The official name of Botox is botulinum toxin. The substance is produced by a bacterium called Clostridium botulinum and is used in a series of medical and aesthetic treatments because of its very powerful muscle relaxation capabilities.
For cases of hyperhidrosis, Botox is applied in regions with a high concentration of sweat glands, discouraging sweat production and considerably reducing sweating for periods that can reach up to 10 months.
The application is made through injections, usually applied to the hands, feet or armpits, inside the doctor’s office. The procedure takes less than 20 minutes and must be repeated once a semester.
Surgeries for hyperhidrosis
Surgical interventions are common treatments for patients who suffer from primary hyperhidrosis, or who have secondary hyperhidrosis and do not respond to other less invasive types of treatment.
In general, the procedures are simple and present very low postoperative risks. However, there is a possibility that, after surgery to treat excessive sweating in one part of the body, the problem will return in a completely different part after some time, in a phenomenon known as compensatory hyperhidrosis.
Removal of axillary sweat glands
The aspiration removal of the sweat glands is a surgical procedure that only shows results for patients who suffer from excessive sweating in the armpits.
The surgery is relatively simple: the doctor makes two very small cuts in the armpits, and, through them, inserts hydrosuction cannulas. These instruments, in turn, remove the sweat glands from the region, aspirating them.
The procedure does not require general anesthesia, only local anesthesia, and the patient can be discharged on the same day, without the need for hospitalization. The greatest postoperative care is to spend the 48 hours following surgery without lifting or making significant efforts with your arms.
Thoracic sympathectomy is a surgical procedure designed to inhibit certain reactions of the sympathetic nervous system that stimulate the excessive production of sweat. It can be used to treat those who suffer from excessive sweating in parts of the body such as the face, neck, scalp, back, chest, abdomen, armpits, hands and feet.
The surgery is done via video, using a long, thin instrument called a thoracoscope, which contains a camera attached to its tip.
The thoracoscope is inserted on one side of the chest and goes to the sympathetic nerve, located near the spinal cord.
With the aid of the surgical instrument, according to the history of each patient, the surgeon can choose to clip part of the nerve or divide it into small pieces. The measure should decrease the stimulation of sweat glands, reducing sweat.
The procedure takes about an hour and requires general anesthesia. It is recommended that the patient avoid any type of physical effort for two weeks.
Alternative treatments for hyperhidrosis
There are some home treatments that can help to decrease your sweating levels.
But beware! These treatments have no proven efficacy and should not replace the conventional treatment recommended by the doctor.
Apple cider vinegar can be used to control sweating in the hands, feet and armpits. The substance has constricting properties that can help to inhibit the excretion of sweat through the pores of these regions.
To bet on apple cider vinegar as an ally against hyperhidrosis, follow these steps:
- Before sleeping, wash the affected area with warm water. Then, dry well with a clean cotton towel;
- Dip a cotton ball in apple cider vinegar and apply well to the chosen region;
- Let the vinegar sit there overnight;
- In the morning, rinse with running water;
- Repeat the procedure at least once a week.
Lemon juice works as a kind of natural antiperspirant. So it is ideal for controlling sweat on your feet, hands and armpits.
To use this natural treatment for hyperhidrosis, follow these steps:
- Squeeze a small fresh lemon;
- Add a teaspoon of baking soda to the lemon juice and mix well until it forms a homogeneous paste;
- Apply the paste where you sweat excessively;
- Let it act for 10 minutes;
- Rinse well under running water;
- Dry well;
- Repeat the procedure once a day.
As hyperhidrosis is a problem that directly affects the individual’s self-esteem, having the help of a psychologist is an important stage of treatment.
Discuss with your doctor the possibility of going to a psychotherapist to work on your insecurities and how you see yourself in the world as a patient with hyperhidrosis.
The professional responsible for your case can choose to prescribe medications that act directly to control the performance of the sweat glands, such as:
It is also possible that the doctor recommends some other products for your treatment, such as:
Your doctor may choose to prescribe some deodorants with special formulas, which can only be produced and purchased at a compounding pharmacy.
There are some specific deodorant lines on the market for the treatment and control of hyperhidrosis.
The best time to apply this type of product is during the night, when people tend to sweat less and the deodorant can be better absorbed by the skin.
Among them are products such as:
- Vichy Stress Resist;
- Vichy Antiperspirant Deodorant 7 Days ;
- Rexona Clinical;
- Dove Clinical;
- M&P Dry.
Sympathetic nervous system inhibitors
Medicines with inhibitory properties of the sympathetic nervous system can significantly help in the treatment of patients with primary hyperhidrosis.
Among the drugs that can be prescribed by your doctor, are:
Antidepressants and anxiolytics
To help control anxiety – which may be causing or being caused by hyperhidrosis – it is common for doctors to prescribe antidepressants as part of the treatment of the disease.
Among the remedies that can be indicated by the health professional, are:
- Fluoxetine Hydrochloride ;
- Venlafaxine hydrochloride ;
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained in this website is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
Hyperhidrosis is usually a difficult problem not only in terms of physical health developments, but also in psychological and social aspects.
Unfortunately, it is common for sweating too much to generate embarrassment, affect the patient’s self-esteem and cause the person with hyperhidrosis to stop practicing certain activities that were once pleasurable.
So, in addition to visiting a specialist who can help you with the causes and origins of your hyperhidrosis, it can also be important to invest in monitoring with psychologists. Therapy can have positive effects on the psychosocial aspects of the disease, helping you to deal with adversity in the best possible way.
Remember that you are a person with many nuances, subjectivities, talents, qualities and unique characteristics. These are the things that define you, not your illness. Hyperhidrosis is a problem that can be controlled, treated and even cured, depending on the cause. You are much bigger than a bad situation.
Some measures that can help improve your quality of life are:
Take extra clothes
Carrying a change of clothes in your backpack or leaving some T-shirts stored in your work closet can be a good way to avoid embarrassment.
Avoid putting too many blouses, one on top of the other, to try to alleviate the problem. Stifling sweat will only make the smell worse, which can negatively affect your self-esteem.
Wear clothes from the right fabrics
Prefer clothes made of natural fabrics, which absorb moisture better, avoiding stains and bad smells during episodes of hyperhidrosis.
Some fabrics that are usually suitable to disguise perspiration are cotton, silk, linen and wool.
Switch your shoe pairs
In most cases, the feet are parts of the body that are very affected by hyperhidrosis. The accumulation of sweat on your shoes can cause odors, which cause embarrassment.
A good outlet is, if possible, to have at least three or four pairs of shoes for everyday life. So, you have a few days to allow your shoes to dry properly and you don’t have to live with the infamous foot odor.
Change your socks
Sweat also accumulates in socks, causing discomfort and a bad smell. So, it is essential to avoid repeating these pieces of clothing as much as possible.
If the situation is bothering you a lot, it is worth changing your socks more than once a day, and even carrying an extra pair in your bag or backpack.
Let your feet breathe
In the rush of routine, it is normal for us to spend many hours with feet stuffed in tight shoes and / or that do not provide adequate conditions for airing the feet.
To avoid the bad smell from the accumulation of sweat, it is important to set aside a few hours of your day to be without socks and shoes, leaving your feet free to take a breath.
It is also worth using the break from work, school or college to go to a place where you can take off your shoes and socks for a while.
Finding other people who experience the same difficulties and situations as you can be an excellent way to live with the problem.
On the internet, it is possible to find several forums, groups, blogs and websites aimed at people who suffer from hyperhidrosis. In these spaces, those who live with the problem exchange tips, stories and reports that can be very important to ensure emotional stability, a sense of belonging and the feeling that, in the end, everything will be okay.
Hyperhidrosis that is not properly treated can, in the long run, cause some complications that affect the health of the skin.
Bromidosis is the clinical name of a bad smell that, believe me, is not natural from sweat. The unpleasant odor comes from the interaction of the liquid with skin bacteria – which, in patients with hyperhidrosis, is intensified by the large accumulation of sweat in certain regions.
Diaper rash is inflammation of the skin, characterized by a bright red color. They are manifestations known to be very common in babies.
They usually appear mainly in regions where there are folds, such as in the armpits and behind the elbows and knees.
In adults with hyperhidrosis, diaper rash is caused by the accumulation of sweat in areas that are frictional areas with clothing.
In addition to causing pain, diaper rash also leaves the region where they are most exposed to fungal and bacterial infections.
Ringworm in the groin
Groin ringworm is a complication that mainly affects people who suffer from secondary hyperhidrosis. The problem happens when there is an accumulation of moisture in the region of the genitals, buttocks and thighs.
Also known as Tinea cruris , the disease is an infection caused by fungi. Although ringworm does not cause serious complications, the problem causes severe itching and the appearance of large red spots in the groin area.
Together, the elements of constant friction and accumulated moisture make the skin more fragile and susceptible to infection by microorganisms.
It is not possible to prevent hyperhidrosis itself, especially in its primary form. The best way to avoid secondary hyperhidrosis is to prevent the diseases that cause the problem.
However, a few simple changes in your lifestyle can prevent bouts of excessive sweating.
Some measures that can prevent excessive sweating are:
Getting in the habit of using antiperspirants is an important step in the process of preventing sweat.
Apply the antiperspirant at least twice a day – preferably before going to sleep or waking up and right after the shower (but only after drying the area where the product will be applied well!).
It is also worth applying an antiperspirant spray on the feet (including the soles and between the toes), to prevent the accumulation of sweat and the consequent bad smell in the region.
Let your feet breathe
Thanks to the demands of routine for more formal clothing, it is common for us not to let our feet breathe properly, always wearing tight or very closed shoes.
Set aside a few hours a day to use only sandals, slippers or even to be barefoot for a while.
For day-to-day life, try investing in shoes made of natural materials, such as leather, for example, or with absorbent soles, especially designed for those who sweat a lot.
Another way out is to invest in sneakers with special holes on the sides and in the front, specially designed so that the foot can be ventilated during the use of the shoes.
Avoid pepper, onion and garlic
If you want to avoid sweating, it is important to reduce the amount of pepper, garlic and onions in your diet.
Pepper increases body temperature, making sweating levels of those who eat it regularly higher. Onions and garlic tend to make the smell of sweat a little worse.
Caffeine is a component that stimulates the sweat glands, significantly increasing the amount of sweat.
So, if you want to avoid sweating, it is important not only to reduce your consumption of coffee, but also drinks like teas, energy drinks and soft drinks.
Stress and nervousness situations directly interfere with the sympathetic nervous system, causing sweat.
Therefore, to avoid excessive sweating, it is important to lead a more peaceful life. Invest in physical activities, healthy eating, more time with loved ones and practicing hobbies that are important to you.
Have a healthy diet
Studies indicate that excess alcohol, fat and sugar on the menu can negatively affect the functioning of the sweat glands. Therefore, having a healthy and balanced diet can be a big step in combating the effects of hyperhidrosis.
Amazingly, contrary to common sense, the more water you drink, the less you sweat.
This is because drinking fluids regulates blood pressure and speeds up metabolism, making the body absorb nutrients more quickly. Water also acts in the lubrication of different parts of the body. This whole process makes the body produce less sweat.
Hyperhidrosis is a problem that causes a lot of discomfort and embarrassment, but it can be easily cured with proper treatment.
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