In Conversation with Specialist Dermatologist Dr. Ryan De Cruz, MD
Dermadry Segments: Dr. Ryan De Cruz
In this episode of Dermadry Segments, we spoke with Dr. Ryan De Cruz, specialist dermatologist & founder of Southern Dermatology about hyperhidrosis, a condition that affects over 5% of the global population. In this interview, Dr De Cruz 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 De Cruz to learn more about excessive sweating, iontophoresis treatment, the importance of opening up about the condition, and his hopes for the future of hyperhidrosis treatment and development.
About Dr Ryan De Cruz
Dr Ryan De Cruz, is a Specialist Dermatologist – Fellow of the Australasian College of Dermatologists (FACD) who is passionate about providing personalised and holistic Dermatological care at his Southern Dermatology clinic. His approach to dermatology is simple: combine outstanding clinical acumen with equal parts communication, genuine care and compassion, and patients from all backgrounds will experience an exceptional clinical outcome.
His interests include eczema, acne and rosacea, psoriasis, skin cancer management, laser treatment and hair loss disorders.
Amanda: Hi, My name is Amanda Colapelle, and welcome to Dermadry Segments. For today's episode, we have Dr. Ryan D. Cruz with us. He is specialized in dermatology. Thank you very much for having us today.
Dr. Ryan De Cruz: Thank you so much for welcoming me.
Amanda: We're going to go through some questions, just a little bit about hyperhidrosis in general, and also about your practice. How did you first become interested in the field of dermatology?
Dr. Ryan De Cruz: So, I first fell in love with the field of dermatology as a medical student, in fact. I undertook some research into a genetic hair condition that affected young children, and it really struck me that diseases of the skin, the hair, and the nails can have a really huge impact on the quality of someone's life, and in some cases even affect the quantity of someone's life. I think the skin really is a fascinating window into the complexity that is the human body. We often see a lot of different medical conditions actually manifesting through the skin. So to be able to understand it and to help people through their skin journey, through health and vitality, was something that I thought was really fascinating and also really rewarding.
Amanda: Thank you very much for sharing your experience and actually just going a little bit more in depth, tell about your experience as a dermatologist, especially in your experience with hyperhidrosis.
Dr. Ryan De Cruz: As a dermatologist, I find that patients often suffer from hyperhidrosis, that is excessive sweating, for months to years before they're actually directed to the right specialty to help them with this condition. I think it's one that's not even recognized by patients as a real medical condition. Even though it's not dissimilar to having high blood pressure or diabetes, eczema or psoriasis. It's a condition that has a real medical basis and often a genetic link as well. Unfortunately, it's under-recognized and patients will often put up with it for many years before seeking treatment or help initially from their general practitioner, before eventually being referred to us. So we're very much thought of right at the end of the day. In terms of treatments for hyperhidrosis, it's definitely something that has often been something that we too have struggled with.
So for many years there were not very many good treatment options to even be able to provide these patients with. So they went on as suffering from this, the stigma and the social isolation and embarrassment that this condition’s caused, and not to mention the functional deficits. So not being able to hold a pen or to shake someone's hand because they're embarrassed, you know, all of these things that have a really significant impact on one's quality of life.
Finally, we're able to offer really good treatments for, so now to me, it's a very exciting time for patients who suffer from hyperhidrosis, but I think still we require a lot of education and to bring these patients out of the woodwork as well.
Amanda: Thank you very much for sharing and that's exactly what we're trying to move forward with. We're trying to build this community sufferers of hyperhidrosis and kind of trying to spread the advocacy. People are sometimes too timid to speak about it, and this is why we want to spread the word. And we founded Dermadry because we had a desire to help those who do suffer from hyperhidrosis. What was your motivation to enter the field of dermatology?
Dr. Ryan De Cruz: Yeah, that's a really good point. I think that the most wonderful aspect of my job is the ability to help people and to help them with their largest organ. If you think about it, one thing that really binds us together as the human race is our skin and although we have very, very many different skin types, whether it be Asian skin, African skin, Australian, or Anglo-Celtic. skin, we all suffer from very similar skin conditions that can look different in different people, but at the end of the day, share a significant commonality. It significantly, however, there are only a few of us, a small number of dermatologists here in Australia. So I often liken it to when I was at school, studying classical languages, I studied Latin and ancient Greek, and only a small number of people did it. But really these two classical languages had a huge impact on the language that we speak today, in our written communication and our history and our culture. In the same way, with skin diseases, there are only a small number of people who really understand it, but we're able to help a huge number of conditions that present to us and also to general practitioners, so I feel like it's something that infiltrates every aspect of our life and when it's not working, when it's dysfunctional can really affect not only our quality of life, but our quantity of life and our ability to function. So to me, it's very rewarding and something that I love to do every day.
Amanda: Thank you for that. That is such an inspiring story, even going back linking the languages. That is something that we, at the end of the day, all connect with. And when we're looking at hyperhidrosis or any type of skin condition in general, we really thank you guys and look up to you guys and, and want your feedback. We want someone to talk to is saying, Hey, can you help me in this certain situation? And I feel like skin is such an important thing to empower somebody and make them feel confident again. Not just speaking about hyperhidrosis, but in general, that's something that is very important. So thank you for sharing.
Dr. Ryan De Cruz: I couldn’t agree with you more.
Amanda: Going forward with the next question. What do you wish the public understood more about your profession?
Dr. Ryan De Cruz: Yeah, that's a really good question. I suspect that, especially in this day and age, with the advent of social media and the world becoming such a small place through the internet, there's a significant misconception that dermatologists are simply beauticians or we're out there to treat, you know, fine lines and wrinkles and fill people with, with artificial injectables or fillers, but in reality, the field of dermatology is incredibly broad and far-reaching. I’d really love people to understand that if they do have problems with their skin of any distance, of any sort or disorder, that they should speak to their general practitioner and specifically request for a referral to a dermatologist because they can often be quite surprised at the sorts of conditions we treat.
It's not uncommon for me to have patients comment to me: “Oh, geez. I didn't even know that you could, you could help me with my sweating” or “I didn't realize that it was a condition”. So to me, I really think that education is key, that we're here to help no matter what the problem is to do with the skin.
Amanda: That's actually a very important point going towards the next question. For hyperhidrosis, there's some individuals who know about it and some who go in saying, “Oh, I think I just have this issue. What is it? Why, why is this happening to me?” So, linking back to the beginning of your practice, what was your first experience with hyperhidrosis when it came to diagnosing the patient?
Dr. Ryan De Cruz: Very interesting. In fact, I first even learned about hyperhidrosis as a junior dermatology trainee. In fact, I came across a young lady who was a new migrant, in fact, a refugee from her own country to Australia. And she was only in the early years of her education, but again, couldn't hold her pen at school and all she wanted to do was study to become a lawyer, eventually. Just a young girl with a big dream and and was very passionate about working hard and unfortunately couldn't even do that at school because of this condition. So it really struck me that this is something that can affect young people and very much influence, their performance at school and their social development.
So what I've understood is that this is an often a genetically mediated condition that can start at a young age and that people who aren't adequately informed about it can often be sort of sidelined as just having a weird sweating problem that no one really understands. They can feel quite socially marginalized as a result of it.
So it is something that I learned about very early on, and it's something that I think we need to educate people about more and more.
Amanda:Yes, definitely. And we've been trying to do some type of polls on our Instagram, on our Facebook community and trying to pinpoint on what they want to know about hyperhidrosis, what do they want to know about excessive sweating?
So the next questions that are coming in are basically questions that were given by the community. And this one is very broad, but what is excessive sweating?
Dr. Ryan De Cruz: So I think excessive sweating can be thought of as a nerve or neurally mediated condition whereby the sweat glands can produce up to five or six times the amount of sweat that is normally required for thermoregulation. So when we think about sweating, it's actually a normal human response designed to keep our body cool, because keeping our core temperature nice and stable is very important to life. However, when we think about excessive sweating, it's where our sweat glands are producing way too much sweat for the given provocation.
So we know that common triggers for sweating could be a warm temperature. And that's quite normal. So in summertime and we're outdoors and enjoying the beach, for example, it's normal that we will sweat to help cool out bodies. But when patients suffer from hyperhidrosis, this sweating response can occur irrespective of what's going on around them. They may be sitting in a cold bedroom studying for the evening and their sweat glands will turn on. Or they may be slightly anxious or nervous about something and yes, it's normal to sweat a little, but these poor patients can sweat excessively and it can be both visible in the clothing that they wear balso again, functional. So preventing them from touching, holding, shaking, hands, embracing all the things that we do every day. That's how I understand hyperhidrosis and how I explain it to my patients.
Amanda: That's really well said. Do you have any tips and tricks that you have given them when it comes to reducing sweat?
Dr. Ryan De Cruz: Thiis can be a really difficult one because ultimately they're trying to tackle a genetic and nerve mediated condition that they have no control of. So, what it ends up being is having to manipulate their environment and their day-to-day life to change it in order to cope with their problems. So for example, patients who have excessively sweaty palms are quite commonly encouraged to carry small hand towels around, to be constantly drying themselves and ensuring that they manipulate their environment to keep it cool, particularly over the warmer months.
But as I mentioned earlier, sometimes it can happen irrespective of temperature changes. Certainly patients who suffer from sort of anxiety and nervousness, I strongly encourage to seek help from their GP or a psychologist. Why? Because we know that when they are more anxious, it will trigger their sweating and that this becomes a self-perpetuating problem because they're sweating, which then triggers more anxiety. So it can be a really difficult one to sort of say to a patient, well, this is what you need to change about your environment or your behaviors, because what they're trying to do is cope with a condition that they have no control of.
Amanda: And we actually have an additional question. There was a patient that was actually asking drinking water. Would it help reduce their sweat?
Dr. Ryan De Cruz: Yeah, it's a common misconception that maybe there's some sort of a relationship between hydration levels and sweating, and unfortunately it's a resounding no. What we know is that it doesn't matter how much one drinks or what they drink, but actually their nerves being overactive and triggering the sweat glands to release sweat, irrespective of their hydration status. So if anything, patients who have suffered from hyperhidrosis may be more prone to dehydration, but the drinking won't help them reduce the amount of sweat that they're producing.
Amanda: Thank you very much for that insight. And we're definitely very excited to share that information and we hope that it helps them viewers as well. When a patient is coming in, when do you first notice the symptoms of excessive sweating? What are symptoms you tend to look for?
Dr. Ryan De Cruz: Yeah. So interestingly, it's as simple as their body language when they first enter the room, because often they won't want to shake your hand. Often they may be wearing layered clothing, for example, a cardigan that will cover their armpits or their axillas and often it's these little subtle signals that you can tell that a patient is quite anxious about the fact that they are excessive sweaters. They’ll commonly wear dark clothing, certainly no whites or grays that will really show up the sweating, and it will really influence that their body language and their behaviors in the consultation. Sometimes they'll tell me, you know, straight up that they suffer from excessive sweating. But often they're quite worried about the odor that they perceive that they're actually producing as well.
And we know that there's not necessarily a correlation between excessive odor and excessive sweating, but in their minds it is quite commonly interlinked. So I often ask patients generally about their family history because there more often than not, there's someone else in their family who may also have suffered from hyperhidrosis.
And then of course we discuss all the other causes of what we call secondary hyperhidrosis. That means an underlying medical condition, usually, that may be triggering excessive sweating as well. And that's really important to exclude that.
Amanda: Living in Australia, do you find that the climate can play a role in hyperhidrosis? Is there studies that have proven any?
Dr. Ryan De Cruz: Well, I'm not familiar with any specific studies, but definitely anecdotally we know that patients with hyperhidrosis will be particularly concerned over the spring and summer months. So for us here in Australia, that's sort of from August through to April, so the opposite of up North, but yeah, there'll commonly be patients who will start to present this time of year because they want to be able to wear lighter clothing or clothing that may be slightly more translucent than that doesn't absorb and show sweat easily. But certainly for the true patients who have suffered from hyperhidrosis from their teenage years, it could be something that persists even through the depths of winter. And certainly my school-aged students who have to wear a shirt, jumper, and then a blazer on top, can be very upset by the fact that they were having to wear all these layers as part of their school uniform, which only drives the hyperhidrosis even more.
Amanda: And now going into the treatments, what are your thoughts on tap water intophoresis, such as Dermadry, as a treatment option for hyperhidrosis?
Dr. Ryan De Cruz: So I think we're at the final point where we're seeing a really well-validated treatment that is cost cost-effective, incredibly safe, and really convenient. And those three factors to me are the most important aspects of iontophoresis, which we've known about for a number of years now but haven't had access to due to costs and due to unfamiliarity with the procedure itself and the treatment. Certainly in Melbourne, Australia, there's only one place in the entire state that has offered hyperhidrosis sufferers iontophoresis, whereby the patients would actually have to go to them and have the treatment on a once to twice weekly frequency.
So that's just simply not practical, especially if you're living far away. So I've often felt quite sad for these patients because we haven't had treatments that they're being able to do at home in the comfort of their own environment, with the frequency that they need. So to have the Dermadry available for them to use and own themselves and run as frequently as they need using something as simple as tap water, I think it's a real groundbreaking treatment that I'm really passionate about promoting to my patients because I'm so confident that it will help them.
Amanda: Oh, we're so excited. And that is something that we've got a lot of feedback on. Um, a lot of dermatologists and patients, especially from Australia were saying, thank you so much for actually creating this, sending this over. And funny story, one of the founders of Dermadry actually suffered severely from hyperhidrosis and he felt like there was not enough treatment options offered out there. So, he really worked hard to speak to patients that were like him and create this device and share his story. So, something like iontopheresis, it has been around for a while and I think having something that is easy to use is good for them.
Dr. Ryan De Cruz: Absolutely.
Amanda: So going into iontophoresis treatment, who is suited for this type of treatment?
Dr. Ryan De Cruz: Well, the good news is that actually the vast majority of patients who suffer from excessive sweating of the palms, the soles and their armpits are usually suitable. It’s such a safe treatment that doesn't require any oral medication.
Really, there are very few patients who aren't suitable or who have what we call contraindications to iontophoresis. It's a treatment that's safe in pregnant ladies, as well as those who are breastfeeding, [note: please speak to your doctor prior to starting treatment if you are pregnant] and certainly those who take a range of oral medications because it simply won't interact with any of them.
So it's a sort of treatment that I have very few patients who I claim that they wouldn't be suitable for the Dermadry or iontophoresis. So I'm pretty happy to promote it to those patients who suffer from hyperhidrosis of their hands, their feet and their armpits.
Amanda: That is another feedback that we were getting from the patients as well. When it came to using other treatments, they were either unsure about them or some were painful, and then got a lot comforting feedback when it came to using iontophoresis. We know that it is a taboo topic. And that is something that we're working on, trying to create that momentum in our community, trying to speak up about the condition. How does a patient usually approach you like about hyperhidrosis or about their sweating?
Dr. Ryan De Cruz: Well, it's a really good question. I think things are changing. In Australia, the general trajectories for a patient to see their general practitioner first and then get a referral to see a dermatologist second.
Now we're seeing that, that this is slowly changing and patients are really quite happy to see assistance from the dermatologist first without actually seeing someone else. The only way that we're going to be able to educate patients is through advertising and through marketing to actually explain to them what they're going through isn't a condition that needs to be suffered in silence. And now with the advent of social media and the internet and email, we're able to actually explain to patients and to reach out to them because no doubt, they've been sitting for hours Googling this at home and trying to work out well of all the treatments that's reported on the internet, what's true and validated what has good medical science behind it.
So I do think it's through directly interacting with patients at home, through their smartphones and devices through their laptop computers explaining that if they are suffering, it's not something that they need to do in silence anymore, and that they can approach us directly for assistance and guidance about excessive sweating.
So I think if things are going to change how patients have even approached this in the past.
Amanda: We're starting to see slowly, but surely that people are feeling a bit more comfortable speaking about it. So, that's why we're really happy to have you on board and let people know that it's okay to speak about it and you're here to listen and you're here to, to help them with their issue as well.
Dr. Ryan De Cruz: Absolutely.
Amanda: Now for the next question, at your clinic Southern Dermatology, have you encountered a patient that is nursing or is pregnant, and has severe hyperhidrosis. If you did, what is usually your treatment procedure like with them?
Dr. Ryan de Cruz: So until recently, all we've had are topical roll-on applications or wipes that the patients have had to use multiple times per day They're often quite irritating to the skin and as a nursing mother, one thing that we see quite commonly is hand dermatitis because of the frequency with which mothers have to wash their hands after nappy changes, constantly immersing them in water and washing the baby, washing the clothing, washing dishes, just these poor mothers that have really troubled hands at the best of times.
So to then ask them to use an irritating or aggressive topical treatment is not something that we like to do, but unfortunately we had really limited other options because they couldn't take the oral medication. So to be able to now offer them a very safe and effective water based treatment is something that I think will, will really be life changing, and in some ways, give these ladies the ability to really gain some of their life and their confidence and look after themselves when all that they've been doing is looking after their babies. So this is something that I think is really exciting for them.
Amanda: And that's something also when it comes to mothers who are pregnant, we're trying to see and find research databases to see if it can be done while the mother's pregnant as well.
So hopefully in the future, that's something that we can also look forward to. As you mentioned, it is a struggle and it's a struggle for them too, having a child and going through all of their ups and downs the pregnancy and still have their excessive sweating issue.
Dr. Ryan De Cruz:
Amanda: What do you wish the public understood more about iontophoresis, such as Dermadry, as a treatment?
Dr. Ryan De Cruz: So I think the reality is the public really don't know much about it at all. And even the word itself by iontophoresis, which is actually, as I mentioned earlier, based in, in the Greek meaning, the carrying of ions. So it's something that they wouldn't know the first thing about, so I think what I'd like to explain to them is that there is now a treatment that they can purchase and have and own themselves and run from their own desk or office space or even their kitchen table that's very safe and effective to treat palmar, plantar and axillary hyperhidrosis. It’s something that they don't need to come back all the time to see a doctor for that they have for the rest of their lives, and it continues to work very efficaciously for the duration of its life span. So it's a device that now we have the ability to be able to pass on directly to patients rather than bringing them into an in-clinic treatment.
So it's very exciting for them and something that I welcome them to Southern Dermatology to come and try before they even have to purchase it. So that's what we're doing here, we're actually saying don't take my word for it, come and actually try it yourself at no cost, and if you believe that you're getting the results that I think you will, you can purchase one for yourself.
So it's really exciting.
Amanda:Yeah. We're very excited. And to start that journey and see the process as well. And we do have a lot of questions that came in speaking about coverage and insurance. So at the moment, is iontophoresis covered by insurance? What's the procedure like when a patient comes in?
Dr. Ryan De Cruz: Sure. So, in Australia, things are quite different from North America, where medical insurance is a very significant part of your healthcare system. We're quite lucky here in Australia, we do have a Medicare system. Currently the Dermadry is not Medicare rebatable. But it is important for each patient to discuss the machine with their own insurer, because there's quite a good chance that their insurance company will provide a rebate for them.
I think this will be a case by case basis, but I think things will, certainly as more and more patients receive, this device, it is TGA approved here in Australia, which is very important. It means that the Australian government recognizes that it is a validated medical device with good evidence behind it.
So that's something that the patient would need to discuss with their own insurer.
Amanda: And when it comes to the insurance coverage, that is something that even hyperhidrosis in general is sometimes not completely recognized. It's really important for the individual to show and state that it is a medical condition and a health condition so the insurances can actually understand and move forward and accept it. So that's something that we're really trying to push toward and spread the word about, so they don't have to worry and they could feel comfortable in their treatment as well.
Dr. Ryan De Cruz: Definitely. And it's one of the things that as a medical professional, we're here to help and we're here to provide, you know, statements and reports that will be able to be used, by these patients to show their insurer that this isn't a made up condition, his is very much a, uh, medically proven condition that needs treatment, like any other.
Amanda: There was another question that came in, concerning does hyperhidrosis indicate other health conditions?
Dr. Ryan De Cruz: Yeah, that's a really good question. And the answer to that is that you can, so we tend to think about a hyperhidrosis in two forms, primary hyperhidrosis, which is really a genetically mediated nerve overactivity problem, whereby the nervous system in that patient's body is sending excessive signals to the sweat clands, telling them to produce sweat. And we don't fully understand it, it's not just one gene and it's not directly inherited necessarily. Although there quite commonly is a family history.
Secondary hyperhidrosis, on the other hand, is the production of excess sweat, often as a result of an underlying medical condition. And there are a number of these, for example, endocrinological or hormone conditions such as thyroid disease or Cushing's disease may be relevant. We also know that patients who suffer from obesity and other metabolic disorders may also produce excessive sweat.
So again, it's important to look at the patient in front of you, understand them as a whole person, as a human, in terms of what other conditions they may have and appropriately investigate them for those conditions, if you think it's relevant. Certainly at a young age, we know that primary hyperhidrosis is probably possibly the most common form of hyperhidrosis. To think of a 12, 13, 14 year old school student suffering at home and being teased on account of this condition and not being able to perform at school, it's really sad.
I think primary hyperhidrosis is a significant issue, but also we always have to investigate the causes of secondary hyperhidrosis too.
Amanda: And we know you mentioned a little bit of tips and tricks, however, is there any stories that come into your head of tips and tricks that you have given to someone who did suffer from hyperhidrosis?
Dr. Ryan De Cruz: So I think the biggest tip that I give patients is it's probably more general than what you might be thinking it's that they don't need to suffer alone, that they need to talk about it to either their parents, to their general practitioner or their dermatologist, because there's no simple tip or trick to get rid of this problem.
It's not something that can be easily switched off, through a particular cream or a tablet. Or item of clothing. And the biggest tip is don't suffer alone in isolation. There are treatments that can help and you just need to come in and speak to one of us. And we're only here to help and only too happy to help.
Amanda: Exactly. And that is something that we're willing to share, and we want to make sure that that there is that open conversation happening through the comments. I think that's something really important to have with everyone, kind of cohesive. So thank you very much for sharing that.Moving forward, we know that there is still a lot of research that needs to be done when it comes to iontophoresis and hyperhidrosis. What are your hopes for the future when it comes to the development of this treatment?
Dr Ryan De Cruz: That's a really good question. I think that the most important thing is to continue to learn and educate ourselves and to make sure that we have really good validated studies that confirm what we know about tap water iontophoresis, amongst large population groups.
You know, these research opportunities are really important at a government and political level, as you say, to make sure that we change the way hyperhidrosis is perceived and to provide further evidence that it is a medical condition that requires as specific treatments and to be able to provide evidence that these treatments are really effective is really important.
So I think ongoing research and development, to be able to bring iontophoresis to more people around the world will be really important. So I I'm a big proponent of ongoing research and development for any treatment that we do, including iontophoresis.
Amanda: And that is something we really hope for too, and we really wanna make sure, for example, speaking to you and getting your point of view and seeing what is the best way to tackle some type of research, what can we do to help support the dermatologists, how can we move forward in that sense. So I'm really excited to see even when it comes to hyperhidrosis for children specifically, I think that would be really brilliant. I think that's a great conversation to have, even when it comes to researchers as well. Before we end off, do you have any final thoughts or stories you would like to share about your unique experience with certain patients that have hyperhidrosis?
Dr. Ryan De Cruz: Well, I guess for me, it's a full circle moment that as a junior registrar, or as a dermatology trainee here in Australia, meeting, young men and women, particularly the lady I mentioned earlier, who just really waanted to study very hard and couldn't even hold it pen.
She was actually forced to come in once a week or even twice a week to one particular center in Melbourne, and now being able to offer it in my own clinic as a test run and then send patients off on their own to do it. It's really a full circle moment for me. So it's very exciting to be able to offer this treatment to patients and to facilitate them purchasing a Dermadry after they've had the opportunity to try it at home. It's something that they'll be able to do forever. And it's very interesting, just two days ago I had two brothers who both suffered from hyperhidrosis and their mother was just extremely happy because she was like, great. I can get one machine that both my and my boys can use and they can share. She was just really happy that there was a treatment that they can both do in the comfort of their own home. So, yeah I'm really excited about this opportunity.
Amanda: That's an amazing story, andI really hope that we could help spread the word in that sense and really make sure that, for example, like the two boys, um, hopefully they're able to stabilize their hyperhidrosis and we're really looking forward to see where we can go on with the research as well.
So thank you very much for coming on today. It was a pleasure speaking to you and thank you for going over all the questions that the community had to share. And for anyone that is in the area in Australia, especially near his clinic please go visit Southern Dermatology, to go visit Dr. Ryan De Cruz.