In Conversation with Dr. Ramin Fathi, MD
Dermadry Segments: Dr. Ramin Fathi, MD
In this episode of Dermadry Segments, we spoke with board-certified dermatologist Dr. Ramin Fathi, MD about his experience dealing with hyperhidrosis. In this interview, Dr Fathi shares his experience and unique insight relating to his experience with diagnosing and treating excessive sweating in his patients.
Watch and read our interview with Dr Fathi to learn more about his career in the field of dermatology, excessive sweating, the impact hyperhidrosis can have on professional advancement, Dermadry's iontophoresis machine, and more!
About Dr Ramin Fathi, MD Board-certified dermatologist and fellowship-trained Mohs surgeon in Phoenix, AZ. Dr. Ramin Fathi founded Phoenix Surgical Dermatology Group with the goal of providing world-class dermatologic care to the state of Arizona. He believes cutting edge healthcare by staff who are dedicated to providing excellence and compassion in a friendly manner is the right of every person.
Dr. Fathi has written over 25 peer-reviewed scientific papers and book chapters and has spoken at national meetings. He is a member and has held committee positions in the American Academy of Dermatology and the American Society of Dermatologic Surgery. Dr. Fathi is board-certified by the American Board of Dermatology.
Interview with Dr. Ramin Fathi, MD
Mathieu: So my name is Mathieu. And today I'm joined by Dr. Ramin. Fathi, a board-certified dermatologist and fellowship trained Mohs surgeon in Phoenix. Dr. Fathi joined Phoenix surgical dermatology group with the goal of providing world-class dermatologic care to the state of Arizona. He has written more than 30 peer-reviewed scientific papers and several books and has spoken at multiple national meetings.He's a member and has held committee positions in the American Academy of Dermatology and the American Society of Dermatologic Surgery. He has represented the American College of Mohs Surgery on Capitol Hill in Washington, DC, advocating for lower drug prices, patient access to care, and overall improvement in the healthcare system.
He has several patients who are affected by hyperhidrosis. And today we'll be talking about how he became an MD and a dermatology expert and how hyperhidrosis can affect an individual's health. Dr. Fathi, it's an immense pleasure to talk to you today, taking the time in your very busy schedule to talk to us about hyperhidrosis. Thank you so much.
Dr. Fathi: I am glad to be here, man. Thanks for having me.
Mathieu: We founded Dermadry about two years ago with the goal of helping people who suffer from hyperhidrosis. We wanted to know what was your motivation to go into dermatology?
Dr. Fathi: Well, for me, I was fortunate enough to grow up around dermatology as my dad was a dermatologist—a retired one. When we were living in Chicago, during that time I remember hanging out at his office all the time and seeing patients coming in and out, and I would see them, they were patients of all backgrounds, all ages. And I just thought, wow, this is really interesting. It's a very diverse population of people coming in and out. So going into medical school, I had an open mind. But when I had a preceptor who was a dermatologist, it kind of sealed the deal, you know. You can make life changing diagnoses in dermatology, you can do surgeries and treat conditions surgically, you could diagnose patients by reading slides.
You can see children, adults, all races, all genders. So everyone, you know, there's really not one person that you wouldn't be able to see. And for me, I was just intrigued that I can diagnose and treat people without racking up in an enormous bill for them. In many other conditions in medicine, to get to a diagnosis sometimes requires imaging or sometimes even surgeries or extensive testing, but in dermatology, we can come up with a diagnosis oftentimes that's life changing without sending the patient home with a crippling bill. So, that also kind of sealed the deal for me.
Mathieu: So it's a very democratic field, I guess.
Dr. Fathi: Yeah. Very great.
Mathieu: So how would you say that when you're studying dermatology, what was the first thing that you learned about hyperhidrosis?
Dr. Fathi: Yeah, so in dermatology you have to go on rotations to try it out. And my first rotation that I ever went on was at the University of Colorado in Denver, and I eventually ended up there for residency. And I remember one patient specifically that we saw at the children's hospital of Colorado. There was an 11 year old boy who had hyperhidrosis of the hands and he was there to get Botox injections into his hands. And I remember myself as an 11 year old, I was deathly afraid of needles. I remember my dad chasing us around the house, trying to draw some blood, to always do our blood tests. And I just realized, this little kid is sitting there talking up 50 pokes to each hand because you know, the sweating has caused him significant disturbance in his social life. I mean, that means a lot. He just sat there and took it like a champ. So I realized, wow, this really does affect quality of life. And that was kind of the first introduction I ever had to hyperhidrosis and excessive sweating in general.
Mathieu: Wow. And did you learn about iontophoresis machines in the university?
Dr. Fathi: Yeah. Subsequently after the University of Colorado ended up doing a rotation at the University of Chicago, and that was the first time I actually heard about iontophoresis. One of my senior attendings at that time said, “Oh, we should try, this patient would be a good candidate for iontophoresis”. He had hyperhidrosis of the hands, and at that time, from what I understood, there really wasn't a good treatment for the underarms, but specifically for the hands and feet, they ordered iontophoresis but it was pretty cumbersome. They had to find a regimen online on different websites, and it just wasn't very smooth. There weren’t very many reviews on it, so we weren't exactly sure what we were prescribing for the patient. We were just hoping that it works.
Mathieu: Absolutely. And since then, do you feel like the studies on iontophoresis machines have evolved?
Dr. Fathi: Yeah. You know, the studies have always been there. I think you can go back to the early nineties and find studies on iontophoresis. Now you're seeing people doing modified iontophoresis where they’re putting different types of medications into the water and kind of trying to get that into the hands.
For example, there's studies that show ‘let's mix iontophoresis with Botox or iontophoresis with. Glycopyrrolate and see if that works better’. So there's some pretty interesting studies on what they're doing, but I think what's nice about it is that it is getting more widely recognized as a great treatment option for patients—it's safe and very effective.
Mathieu: Yep. As you may know, we also think that iontophoresis is a very effective treatment. We'll get to that, but can you tell us a little bit what a typical day of a dermatologist looks like?
Dr. Fathi: For me I am a Mohs trained surgeon and a board certified dermatologist. So it's quite different every day. There's some days where I'm dedicated to just doing surgery, where I've skin cancer patients coming in and we remove the skin cancer and then do the reconstructive surgery, same day. Other days, I'm seeing general dermatology and cosmetic dermatology, where patients come in for any sort of complaint pertaining to the skin, whether it's a patient with acne, warts, hyperhidrosis, or a rash. We see whatever comes through the door. Aside from that, I'm pretty active in telemedicine and I have a couple of positions where I see patients online in between my in-person patients. So, it’s pretty non-stop start to finish, but it's very rewarding.
Mathieu: I can imagine. So I'm sure, you know, hyperhidrosis is commonly described as the “silent handicap” because people who have hyperhidrosis don't want to talk about it to their parents, their friends, even their doctors. How would you say is the most common way patients address or approach you about their hyperhidrosis?
Dr. Fathi: I didn't even know it was called that, but I can see that that term fits really well. For me, when the patients come to the dermatologist and they are motivated enough to see the dermatologist at that point, you know that it's been a problem that they've been thinking about, it they’ve been fixating on it for awhile, and they've probably already tried a prescription strength topical medication. They probably already tried some of those things, early regimens, and they've done their research. Our patients are really smart these days. You know, they have access to a lot of the information that we have access to so they know what they're looking for. So, I've had patients come in who are looking for iontophoresis machines right away. I also have patients come in who don't know anything about iontophoresis, and are surprised when I tell them about it. And they're really excited when they hear about it.
Mathieu: Yeah, absolutely. Yeah. That's something that we're also very surprised about—how smart our patients are. They already know about all the alternatives, they tried most of them, they know all about the difference between hyperhidrosis type one and type two. So it's amazing how the internet can educate patients before they come to us, asking for answers. Do you see any type of typical patient who suffers from hyperhidrosis or who feels comfortable to admit that they have hyperhidrosis?
Dr. Fathi: Patients, when they come to me, obviously they're having issues. In my eyes. I see hyperhidrosis patients in a couple of ways, one is the social, there's the patients who suffer socially from their hyperhidrosis. Whether it's a teenager who's in school, who's getting picked on because he's sweating too much, he's afraid to ask a girl out on a date, for example, is in college and it just impacts their quality of life because it stops them from doing the normal things that you should be doing. There’s no medical condition that should be holding you back to live your life at its fullest.
On the other hand, I see patients who are impacted professionally from their hyperhidrosis. So I've seen professional athletes who get excessive sweating of the hands. And for them, that's a big deal whenever they're playing sports. I mean, do you need to have a good grip when you're playing basketball or football or baseball, for example. So, in that setting, it is a big deal for them. I mean, they may not be impacted socially, or they may not be embarrassed about it, but even what you consider mild hyperhidrosis makes a significant difference in their day-to-day life. For example, a surgeon having excessive sweating of the hands, that can significantly impact the quality of their work.
There's some patients who will refuse to wear certain colors of clothing because they're afraid of the color change when the sweat seeps through. There's so many different areas that it can affect your life, either socially or professionally.
Mathieu: Absolutely. We recently just did a scholarship. So basically we wanted to give a bursary to the student. Of course, every student deserves to have an entry for this iontophoresis machine, but the person who had the most heartwarming story, and we heard so many different stories. For example, one person who had the best grades out of her school went to the gym every day because her life dream was to become a pilot for the army. And sadly, she passed all the tests and at her last-ever training, her instructors looked at her hands and saw the hyperhidrosis. And because of that, they told her that she couldn't be a pilot in the army and it just completely devastated her. So, it really has a profound effect on people's life. And I think a lot of people don't realize that—they see it as a mundane problem, but you know, it really has a deep impact.
Of course, without giving names, do you have any stories about people who have hyperhidrosis and how it affected their lives and how they had to go through those situations.
Dr. Fathi: Yeah. So just today I saw a followup patient who's a well-known physician who speaks professionally, and the only issue is that she has hyperhidrosis of the underarms.
So what does that mean for her? She can't wear certain clothes when she speaks, she always has to wear black. And for her, when she wears black, it makes her seem a little bit more serious, a little bit more “not as light”. So for that reason, she thinks that really does impact the way patients or other people perceive her. I think everyone should be able to wear colors, be able to wear gray tones, if that makes you happy. You can go down the list, there are kids who basically gain confidence as much as they get from using Accutane to treat their acne, to athletes who become better at sports as a result of treating their hyperhidrosis. So, yeah there is a significant impact to treating people's hyperhidrosis.
Mathieu: Absolutely. So I don't know if you were aware of this, but studies have shown that people who suffer from hyperhidrosis are three times more prone to have either depression or severe anxiety, because it really affects their day to day life. I wanted to know what were your thoughts on this? Is this something that you also see in your clinic?
Dr. Fathi; Yeah. I'm not surprised by that. Especially in our younger generation of patients, I feel like that would be a significant impact in their day-to-day life. Aside from that, any dermatologic disease that is on the outside and people can see it, it definitely impacts our sense of wellbeing.
So kids, for example, I mean, bullying these days is a big problem. I don't know how bad it is in Canada, but in the States it's an issue. You know, kids can be pretty ruthless, they pick on anything they can, they can find to pick on. So, I totally believe that.
Mathieu: Yeah, well, thankfully there are treatment options for hyperhidrosis. That's one of the reasons why we wanted to talk to you today. And how do you feel when you recommend iontophoresis, and Dermadry more specifically, to treat hyperhidrosis?
Dr. Fathi: Well, I feel great about it. Usually when patients come to me, they've already tried the topicals. If not, I'd like to start with a prescription strength topical because the risk of it is so low and the benefit, it can only help. After that if they have already tried that or they want to go that extra mile, in medicine, every medical student has to take the Hippocratic oath and one of those things is do no harm.So for that, we're always looking for treatments that have great benefits, but really minimal risk. And iontophoresis is one of those treatments that really is low-risk with significant benefits. So, if you have 20 minutes, three times a week, this is a great treatment option for you. So when I tell patients about this, they're really excited. When you consider some of the alternatives, what's not to be excited about iontophoresis? For one is talking about botulinum toxin injections, it wears off after three months. It’s really, really expensive and requires several dozens of pokes and it's not pain-free. In America, it's tough to even get patients' insurance to cover that a lot of times.
Another option is a medication by mouth called glycopyrrolate, one of the anticholinergic medications, and they work, they do a great job, but when you're introducing a medicine systemically, you have side effects from it. What are those side effects? Heart palpitations, dry mouth, dry eyes, blurry vision, those are side effects that could significantly impact one's body and life and even be somewhat dangerous. So, iontophoresis is one of those treatment options that really does work, but also the side effect profile is really minimal. So, after I start topical, that's really one of my first line treatments to go to, if not be first line treatment.
Mathieu: Yeah, absolutely. Well, thank you so much for that. And, and is every patient fit to have iontophoresis treatment?
Dr. Fathi: Well, there's some patients that are excluded obviously. If you're pregnant or planning pregnancy, or suspect pregnancy iontophoresis is contra-indicated for you. And if you have any sort of implantable cardiac device, like a pacemaker, defibrillator, deep brain stimulator, you would be excluded from iontophoresis. Even metallic implants would be a contraindication as well, but for the vast majority of the public, this could be a great option.
Mathieu: And those are really important things to take under consideration. So how do people usually react when you tell them about iontophoresis? Because we always get these “big eyes” when we tell them, you know, put your hands in a bucket of water, that's going to contain some mild electrical current, other people say, you know, that's exactly what my parents always told me not to do. So what are usually the misconceptions that people have around iontophoresis and how do people initially react when you tell them about this solution?
Dr. Fathi: Yeah. Well, you have to understand that a lot of the patients that come to me, especially on telemedicine, they already know about iontophoresis and they're actively seeking iontophoresis. So those patients are easy right, I don't have to convince them of anything. When I do talk to patients, I explain all the different treatment options. I tell them about Botox, I tell them about microwave technology for your underarms, I tell them about anticholinergic medications and the wipes and I tell them about iontophoresis and I tell them, if it was for me, that's the one I would start with. And when they hear about it, I get a couple of different reactions. I get the “is this for real?” and then I also get the “wow, that is so cool” look. So I get a couple of mixed looks, but overall, when you explain all the treatment options to someone, they trust you and they understand that you're looking out for their best interest and they're on board. I don't think I've had one patient that wasn't on board when they hear the side effect profile is minimal and the benefits can be great.
Mathieu: Amazing. So, what do your patients usually feel when they use an iontophoresis machine? Can you tell us about the good cases and even the bad cases so people know what they're getting into?
Dr. Fathi: I always tell them if you want it to be a slight, slight, slight discomfort, you want to ramp up that iontophoresis machine to be just slightly uncomfortable, not completely uncomfortable, but very tolerable. And that's kind of the recommended way to use it. You want to get it up there and you want to do it about 20 minutes, three times a week until you're starting to see the sweating to that level that you really like. And at that point you can switch over to a more sustainable regimen. That regimen could be anywhere from once a week, and if it's doing well with once a week, you can even try going to every other week, if every other week works really well, you can stick with that. You just want to find that kind of sweet spot of how often you have to use it for it to actually work for you. But really I tell patients, you should be able to just sit, watch TV, FaceTime with a friend, do whatever. And if you have 20 minutes where you're sitting around, perfect time to do Dermadry. It’s a really quick procedure and really it doesn't take away from your day to day.
Mathieu: Great. And what would you say the success rate is that you see with your patients?
Dr. Fathi: I'd say it's pretty good. I'd say it's not a hundred percent, obviously nothing's perfect in medicine, but definitely greater than 50% of my patients, upwards of 70% are very, very happy with the results. And even those who don't get exactly what they're looking for, they do notice some benefit from it. So, I would say it is successful, for sure. On the wide spectrum of patients, some patients have a little bit extra, but this definitely does help to kind of bring them down a little bit. It is one of those treatment options where I feel comfortable sending a patient home and they're on board and they're in there, they're happy, they're very happy.
Mathieu: So, this is one of the main advantages that we see for machines. As you said, you give the machine to the person and he goes home and he does it in the comfort of his own home. He doesn't always need to come back to the clinic, he doesn't need to do it under any type of health professional. So we really feel that it really helps to democratize the treatment of hyperhidrosis. I don't know if you have an opinion about that?
Dr. Fathi: Yeah. I mean, I think that's great. I think especially in this day and age with COVID-19, I think “who wants to come to the office every week or every three months” for whatnot for a treatment when you can just be doing it at home. And I think this is the importance of telemedicine in treating hyperhidrosis. I think it's, it's a slam dunk marriage because people can be at home in their house and get a prescription for this without ever having to leave or go to the doctor's office. It's as easy as it could ever be and it gets mailed to you. You really don't have to do anything. It's really straightforward and I'm surprised it took this long to get this to happen. But, I think one of the silver linings of COVID-19 is that it really ramped up telemedicine and the access that patients have to really high quality care.
Mathieu: Yeah. So what is your opinion about telemedicine exactly in this age of COVID? What do you see in terms of the treatment of hyperhidrosis, in this case?
Dr. Fathi: Yeah, so even before COVID, I was heavily involved in telemedicine. I actually served on the American Academy of Dermatology telemedicine task force several years ago when it was just starting to pick up. So I was still seeing patients in Arizona, California, and Texas, prior to COVID. And then when COVID happened, or it started, then things really became more busy in telemedicine. I had noticed that a lot of patients don't want to go into the office anymore, they really want to do it from the comfort of their own home. For many conditions, telemedicine is tough. For skin cancer, it’s really hard to kind of look at it through a photo. Hyperhidrosis, you know, the patient makes the diagnosis. If you're suffering from excessive sweating, you can send me a photo if you're having problems with sweating and it's impacting your day to day life, you have hyperhidrosis. The patients don't come to me for me to diagnose hyperhidrosis, they come to me for a treatment option. So at that point, telemedicine is perfect. They don't have to come all the way out to see me. Oftentimes, a lot of patients are directed towards me through Dermadry and through a telemedicine platform I use called SkyMD and they're specifically requesting it. So I think in this day and age, I think for many conditions, but especially hyperhidrosis, telemedicine is really a great marriage.
Mathieu: So my last question for you would be, what do you see as the future of hyperhidrosis treatment? And if you had something to say for patients out there who have hyperhidrosis and don't feel comfortable talking about it to their family or even their doctor, is there hope?
Dr. Fathi: Yeah, those are great questions. So for the future, I think we're in the future right now and hopefully things get even better. Right now we're seeing patients who didn't have access to a dermatologist in rural parts of the country who can now log in and get someone in a big city or somewhere else and get an iontophoresis machine shipped to their house.
I think we're only going to see more research go into iontophoresis and the benefits of it. We're going to probably see moore research into using iontophoresis with other treatment options, such as mixing it with glycopyrrolate, seeing iIf that works better than just water alone, mixing it with Botox, and seeing if that makes it work better than just water alone.
I think there's some interesting things that people have come up with. I think we're going to start to see a lot more topical medications in hyperhidrosis too, down the line. So that’s really exciting for the field of hyperhidrosis for those patients who are sitting at home who are too embarrassed or worried about seeing a dermatologist.
It’s never been easier, you can just go online, you can see your dermatologist and basically that day we'll have an iontophoresis machine or treatment plan specifically targeted to help you, sent directly to your home. It's completely anonymous, it's just never been easier.
Mathieu: So it's exciting times if you're suffering from hyperhidrosis, it's never been easier to treat your condition, basically.
Dr. Fathi: Right now yes, absolutely.
Mathieu: Well, you know what? I know, there's a lot of patients waiting for you out there and people who suffer from hyperhidrosis, but the other conditions. So I'll let you go, but I really wanted to thank you for sharing all your knowledge about hyperhidrosis and about telemedicine, and I'm convinced that we're going to be able to talk in the future as well.
Dr. Fathi: I appreciate it, Matt. It was good talking to you.