Hyperhidrosis

Last updated
Hyperhidrosis
Other namesPolyhidrosis, sudorrhea
Hyperhidrosis Treatment.jpg
Specialty Dermatology

Hyperhidrosis is a condition characterized by abnormally increased sweating, [1] [2] in excess of that required for regulation of body temperature. [3] Although primarily a benign physical burden, hyperhidrosis can deteriorate quality of life from a psychological, emotional, and social perspective. [4] In fact, hyperhidrosis almost always leads to psychological as well as physical and social consequences. [5] People suffering from it present difficulties in the professional field, more than 80% experiencing a moderate to severe emotional impact from the disease [6] and half are subject to depression.

Contents

This excess of sweat happens even if the person is not engaging in tasks that require muscular effort, and it does not depend on the exposure to heat. [7] Common places to sweat can include underarms, face, neck, back, groin, feet, and hands. It has been called by some researchers 'the silent handicap'. [8]

Both diaphoresis and hidrosis can mean either perspiration (in which sense they are synonymous with sweating [9] [10] ) or excessive perspiration, in which case they refer to a specific, narrowly defined, clinical disorder.

Classification

Visual scale for the quantification of hyperhidrosis Visual scale for the quantification of hyperidrosis.tif
Visual scale for the quantification of hyperhidrosis

Hyperhidrosis can either be generalized, or localized to specific parts of the body. Hands, feet, armpits, groin, and the facial area are among the most active regions of perspiration due to the high number of sweat glands (eccrine glands in particular) in these areas. When excessive sweating is localized (e.g. palms, soles, face, underarms, scalp) it is referred to as primary hyperhidrosis or focal hyperhidrosis. Excessive sweating involving the whole body is termed generalized hyperhidrosis or secondary hyperhidrosis. It is usually the result of some other, underlying condition.[ citation needed ]

Primary or focal hyperhidrosis may be further divided by the area affected, for instance, palmoplantar hyperhidrosis (symptomatic sweating of only the hands or feet) or gustatory hyperhidrosis (sweating of the face or chest a few moments after eating certain foods). [1]

Hyperhidrosis can also be classified by onset, either congenital (present at birth) or acquired (beginning later in life). Primary or focal hyperhidrosis usually starts during adolescence or even earlier and seems to be inherited as an autosomal dominant genetic trait. It must be distinguished from secondary hyperhidrosis, which can start at any point in life, but usually presents itself after 25 years of age. Secondary hyperhidrosis commonly accompanies conditions such as diabetes mellitus, Parkinson's disease, hyperthyroidism, hyperpituitarism, anxiety disorder, pheochromocytoma, and menopause. [11]

One classification scheme uses the amount of skin affected. [12] In this scheme, excessive sweating in an area of 100 square centimeters (16 square inches) or more is differentiated from sweating that affects only a small area. [13]

Another classification scheme is based on possible causes of hyperhidrosis.[ citation needed ]

Causes

The cause of primary hyperhidrosis is unknown. Anxiety or excitement can exacerbate the condition. A common complaint of people is a nervous condition associated with sweating, then sweat more because the person is nervous. Other factors can play a role, including certain foods and drinks, nicotine, caffeine, and smells.[ citation needed ]

Similarly, secondary (generalized) hyperhidrosis has many causes including certain types of cancer, disturbances of the endocrine system, infections, and medications.[ citation needed ]

Primary

Primary (focal) hyperhidrosis has many causes.

Cancer

A variety of cancers have been associated with the development of secondary hyperhidrosis including lymphoma, pheochromocytoma, carcinoid tumors (resulting in carcinoid syndrome), and tumors within the thoracic cavity. [4]

Endocrine

Certain endocrine conditions are also known to cause secondary hyperhidrosis including diabetes mellitus (especially when blood sugars are low), acromegaly, hyperpituitarism, pheochromocytoma (tumor of the adrenal glands, present in 71% of patients) and various forms of thyroid disease. [4]

Medications

Use of selective serotonin reuptake inhibitors (e.g., sertraline) is a common cause of medication-induced secondary hyperhidrosis. [4] Other medications associated with secondary hyperhidrosis include tricyclic antidepressants, stimulants, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), glyburide, insulin, anxiolytic agents, adrenergic agonists, and cholinergic agonists. [4]

Miscellaneous

Diagnosis

Symmetry of excessive sweating in hyperhidrosis is most consistent with primary hyperhidrosis. [4] To diagnose this condition, a dermatologist gives the person a physical exam. This includes looking closely at the areas of the body that sweat excessively. A dermatologist also asks very specific questions. This helps the physician understand why the person has excessive sweating. Sometimes medical testing is necessary. Some patients require a test called the sweat test. This involves coating some of their skin with a powder that turns purple when the skin gets wet.[ citation needed ]

Excessive sweating affecting only one side of the body is more suggestive of secondary hyperhidrosis and further investigation for a neurologic cause is recommended. [4]

Treatment

Antihydral cream is one of the solutions prescribed for hyperhidrosis for palms. [14] [15] Topical agents for hyperhidrosis therapy include formaldehyde lotion, topical anticholinergics etc. These agents reduce perspiration by denaturing keratin, in turn occluding the pores of the sweat glands. They have a short-lasting effect. Formaldehyde is classified as a probable human carcinogen. Contact sensitization is increased, especially with formalin. Aluminium chlorohydrate is used in regular antiperspirants. However, hyperhidrosis requires solutions or gels with a much higher concentration. These antiperspirant solutions or hyperhidrosis gels are especially effective for treatment of axillary or underarm regions. Normally it takes around three to five days to see improvement. The most common side-effect is skin irritation. For severe cases of plantar and palmar hyperhidrosis, there has been some success with conservative measures such as higher strength aluminium chloride antiperspirants. [16] Treatment algorithms for hyperhidrosis recommend topical antiperspirants as the first line of therapy for hyperhidrosis. Both the International Hyperhidrosis Society and the Canadian Hyperhidrosis Advisory Committee have published treatment guidelines for focal hyperhidrosis that are said to be evidence-based.

Prescription medications called anticholinergics, often taken by mouth, are sometimes used in the treatment of both generalized and focal hyperhidrosis. [17] Anticholinergics used for hyperhidrosis include propantheline, glycopyrronium bromide or glycopyrrolate, oxybutynin, methantheline, and benzatropine. Use of these drugs can be limited, however, by side-effects, including dry mouth, urinary retention, constipation, and visual disturbances such as mydriasis (dilation of the pupils) and cycloplegia. For people who find their hyperhidrosis is made worse by anxiety-provoking situations (public speaking, stage performances, special events such as weddings, etc.), taking an anticholinergic medicine before the event may be helpful. [18]

Several anticholinergic drugs can reduce hyperhidrosis. Oxybutynin (brand name Ditropan) is one that has shown promise, [16] [19] although it can have side-effects, such as drowsiness, visual symptoms and dryness of the mouth and other mucous membranes. Glycopyrrolate is another drug sometimes used. It is said to be nearly as effective as oxybutynin, but has similar side-effects. In 2018, the U.S. Food and Drug Administration (FDA) approved the topical anticholinergic glycopyrronium tosylate (brand name Qbrexza) for the treatment of primary axillary hyperhidrosis. [20] [21]

For peripheral hyperhidrosis, some people have found relief by simply ingesting crushed ice water. Ice water helps to cool excessive body heat during its transport through the blood vessels to the extremities, effectively lowering overall body temperature to normal levels within ten to thirty minutes. [22]

Procedures

Injections of botulinum toxin type A can be used to block neural control of sweat glands. The effect can last from 3–9 months depending on the site of injections. [23] This use has been approved by the U.S. Food and Drug Administration (FDA). [24] The duration of the beneficial effect in primary palmar hyperhidrosis has been found to increase with repetition of the injections. [25] The Botox injections tend to be painful. Various measures have been tried to minimize the pain, one of which is the application of ice.

This was first demonstrated by Khalaf Bushara and colleagues as the first nonmuscular use of BTX-A in 1993. [26] BTX-A has since been approved for the treatment of severe primary axillary hyperhidrosis (excessive underarm sweating of unknown cause), which cannot be managed by topical agents.[ when? ] [27] [28]

A microwave-based device has been tried for excessive underarm perspiration and appears to show promise. [29] With this device, rare but serious side effects exist and are reported in the literature, such as paralysis of the upper limbs and brachial plexus. [30]

Tap water iontophoresis as a treatment for palmoplantar hyperhidrosis was originally described in the 1950s. [31] Studies showed positive results and good safety with tap water iontophoresis. [32] One trial found it decreased sweating by about 80%. [33]

Surgery

Sweat gland removal or destruction is one surgical option available for axillary hyperhidrosis (excessive underarm perspiration). There are multiple methods for sweat gland removal or destruction, such as sweat gland suction, retrodermal curettage, and axillary liposuction, Vaser, or Laser Sweat Ablation. Sweat gland suction is a technique adapted for liposuction. [34]

The other main surgical option is endoscopic thoracic sympathectomy (ETS), which cuts, burns, or clamps the thoracic ganglion on the main sympathetic chain that runs alongside the spine. Clamping is intended to permit the reversal of the procedure. ETS is generally considered a "safe, reproducible, and effective procedure and most patients are satisfied with the results of the surgery". [35] Satisfaction rates above 80% have been reported, and are higher for children. [36] [37] The procedure brings relief from excessive hand sweating in about 85–95% of people. [38] ETS may be helpful in treating axillary hyperhidrosis, facial blushing and facial sweating, but failure rates in people with facial blushing and/or excessive facial sweating are higher and such people may be more likely to experience unwanted side effects. [39]

ETS side-effects have been described as ranging from trivial to devastating. [40] The most common side-effect of ETS is compensatory sweating (sweating in different areas than prior to the surgery). Major problems with compensatory sweating are seen in 20–80% of people undergoing the surgery. [41] [42] [43] Most people find the compensatory sweating to be tolerable while 1–51% claim that their quality of life decreased as a result of compensatory sweating." [36] Total body perspiration in response to heat has been reported to increase after sympathectomy. [44] The original sweating problem may recur due to nerve regeneration, sometimes as early as 6 months after the procedure. [41] [42] [45]

Other possible side-effects include Horner's Syndrome (about 1%), gustatory sweating (less than 25%) and excessive dryness of the palms (sandpaper hands). [46] Some people have experienced cardiac sympathetic denervation, which can result in a 10% decrease in heart rate both at rest and during exercise, resulting in decreased exercise tolerance. [47]

Percutaneous sympathectomy is a minimally invasive procedure similar to the botulinum method, in which nerves are blocked by an injection of phenol. [48] The procedure provides temporary relief in most cases. Some physicians advocate trying this more conservative procedure before resorting to surgical sympathectomy, the effects of which are usually not reversible.

Prognosis

Hyperhidrosis can have physiological consequences such as cold and clammy hands, dehydration, and skin infections secondary to maceration of the skin. Hyperhidrosis can also have devastating emotional effects on one's individual life. [49]

Those with hyperhidrosis may have greater stress levels and more frequent depression. [50]

Excessive sweating or focal hyperhidrosis of the hands interferes with many routine activities, [51] such as securely grasping objects. Some people with focal hyperhidrosis sufferers avoid situations where they will come into physical contact with others, such as greeting a person with a handshake. Hiding embarrassing sweat spots under the armpits limits the affected person's arm movements and pose. In severe cases, shirts must be changed several times during the day and require additional showers both to remove sweat and control body odor issues or microbial problems such as acne, dandruff, or athlete's foot. Additionally, anxiety caused by self-consciousness to the sweating may aggravate the sweating. Excessive sweating of the feet makes it harder for people to wear slide-on or open-toe shoes, as the feet slide around in the shoe because of sweat. [52]

Some careers present challenges for people with hyperhidrosis. For example, careers that require the use of a knife may not be safely performed by people with excessive sweating of the hands. The risk of dehydration can limit the ability of some to function in extremely hot (especially if also humid) conditions. [53] Even the playing of musical instruments can be uncomfortable or difficult because of sweaty hands. [54]

Epidemiology

It is estimated that the incidence of focal hyperhidrosis may be as high as 2.8% of the population of the United States. [51] It affects men and women equally, and most commonly occurs among people aged 25–64 years, though some may have been affected since early childhood. [51] About 30–50% of people have another family member affected, implying a genetic predisposition. [51]

In 2006, researchers at Saga University in Japan reported that primary palmar hyperhidrosis maps to gene locus 14q11.2–q13. [55]

Related Research Articles

<span class="mw-page-title-main">Perspiration</span> Fluid secreted from sudoriferous glands

Perspiration, also known as sweat, is the fluid secreted by sweat glands in the skin of mammals.

Iontophoresis is a process of transdermal drug delivery by use of a voltage gradient on the skin. Molecules are transported across the stratum corneum by electrophoresis and electroosmosis and the electric field can also increase the permeability of the skin. These phenomena, directly and indirectly, constitute active transport of matter due to an applied electric current. The transport is measured in units of chemical flux, commonly μmol/(cm2*hour). Iontophoresis has experimental, therapeutic and diagnostic applications.

Body odor or body odour (BO) is present in all animals and its intensity can be influenced by many factors. Body odor has a strong genetic basis, but can also be strongly influenced by various factors, such as sex, diet, health, and medication. The body odor of human males plays an important role in human sexual attraction, as a powerful indicator of MHC/HLA heterozygosity. Significant evidence suggests that women are attracted to men whose body odor is different from theirs, indicating that they have immune genes that are different from their own, which may produce healthier offspring.

<span class="mw-page-title-main">Axilla</span> Area of the human body beneath the joint between arm and torso

The axilla is the area on the human body directly under the shoulder joint. It includes the axillary space, an anatomical space within the shoulder girdle between the arm and the thoracic cage, bounded superiorly by the imaginary plane between the superior borders of the first rib, clavicle and scapula, medially by the serratus anterior muscle and thoracolumbar fascia, anteriorly by the pectoral muscles and posteriorly by the subscapularis, teres major and latissimus dorsi muscle.

Endoscopic thoracic sympathectomy (ETS) is a surgical procedure in which a portion of the sympathetic nerve trunk in the thoracic region is destroyed. ETS is used to treat excessive sweating in certain parts of the body, facial blushing, Raynaud's disease and reflex sympathetic dystrophy. By far the most common complaint treated with ETS is sweaty palms. The intervention is controversial and illegal in some jurisdictions. Like any surgical procedure, it has risks; the endoscopic sympathetic block (ESB) procedure and those procedures that affect fewer nerves have lower risks.

<span class="mw-page-title-main">Sweat gland</span> Small sweat-producing tubular skin structures

Sweat glands, also known as sudoriferous or sudoriparous glands, from Latin sudor 'sweat', are small tubular structures of the skin that produce sweat. Sweat glands are a type of exocrine gland, which are glands that produce and secrete substances onto an epithelial surface by way of a duct. There are two main types of sweat glands that differ in their structure, function, secretory product, mechanism of excretion, anatomic distribution, and distribution across species:

<span class="mw-page-title-main">Glycopyrronium bromide</span> Chemical compound

Glycopyrronium bromide is a medication of the muscarinic anticholinergic group. It does not cross the blood–brain barrier and consequently has few to no central effects. It is given by mouth, via intravenous injection, on the skin, and via inhalation. It is a synthetic quaternary ammonium compound. The cation, which is the active moiety, is called glycopyrronium (INN) or glycopyrrolate (USAN).

Hemifacial spasm (HFS) is a rare neuromuscular disease characterized by irregular, involuntary muscle contractions (spasms) on one side (hemi-) of the face (-facial). The facial muscles are controlled by the facial nerve, which originates at the brainstem and exits the skull below the ear where it separates into five main branches.

<span class="mw-page-title-main">Harlequin syndrome</span> Medical condition

Harlequin syndrome is a condition characterized by asymmetric sweating and flushing on the upper thoracic region of the chest, neck and face. Harlequin syndrome is considered an injury to the autonomic nervous system (ANS). The ANS controls some of the body's natural processes such as sweating, skin flushing and pupil response to stimuli. Individuals with this syndrome have an absence of sweat skin flushing unilaterally, usually on one side of the face, arms and chest. It is an autonomic disorder that may occur at any age. Harlequin syndrome affects fewer than 1000 people in the United States.

<i>Trichobacteriosis axillaris</i> Medical condition

Trichobacteriosis axillaris is a superficial bacterial colonization of the hair shafts in sweat gland–bearing areas, such as the armpits and the groin. It is a trivial disease of worldwide occurrence that is believed to be caused by the genus Corynebacteria.

<span class="mw-page-title-main">Oxybutynin</span> Medication for overactive bladder

Oxybutynin, sold as under the brand name Ditropan among others, is an anticholinergic drug primarily used to treat overactive bladder. It is widely considered a first-line therapy for overactive bladder due to its well-studied side effect profile, broad applicability, and continued efficacy over long periods of time. It works similar to tolterodine, darifenacin, and solifenacin, although it is usually preferred over these medications. It is sometimes used off-label for treatment of hyperhidrosis, or excessive sweating. It has also been used off-label to treat bed wetting in children, but this use has declined, as it is most likely ineffective in this role. It is taken by mouth or applied to the skin.

<span class="mw-page-title-main">Compensatory hyperhidrosis</span> Medical condition

Compensatory hyperhidrosis is a form of neuropathy. It is encountered in patients with myelopathy, thoracic disease, cerebrovascular disease, nerve trauma or after surgeries. The exact mechanism of the phenomenon is poorly understood. It is attributed to the perception in the hypothalamus (brain) that the body temperature is too high. The sweating is induced to reduce body heat.

<span class="mw-page-title-main">Frey's syndrome</span> Medical condition

Frey's syndrome is a rare neurological disorder resulting from damage to or near the parotid glands responsible for making saliva, and from damage to the auriculotemporal nerve often from surgery.

<span class="mw-page-title-main">Cholinergic urticaria</span> Medical condition

Cholinergic urticaria is a type of hives (urticaria) that is triggered by an increase in body temperature, such as during exercise, sweating, or exposure to heat. It is also sometimes called exercise-induced urticaria or heat hives. The condition is caused by an overreaction of the immune system to the release of histamine and other chemicals in response to the increase in body temperature. This results in the characteristic red, itchy, and sometimes raised bumps or welts on the skin that are associated with hives.

Hypohidrosis is a disorder in which a person exhibits diminished sweating in response to appropriate stimuli. In contrast with hyperhidrosis, which is a socially troubling yet often benign condition, the consequences of untreated hypohidrosis include hyperthermia, heat stroke and death. An extreme case of hypohidrosis in which there is a complete absence of sweating and the skin is dry is termed anhidrosis.

Gustatory hyperhidrosis is excessive sweating classified under focal hyperhidrosis, that is, it is restricted to certain regions of the body. Affected people regularly experience this on the forehead (scalp), upper lip, perioral region, or sternum a few moments after eating spicy foods, tomato sauce, chocolate, coffee, tea, or hot soups.

<span class="mw-page-title-main">Focal hyperhidrosis</span> Excessive sweating in certain body regions

Focal hyperhidrosis, also known as primary hyperhidrosis, is a disease characterized by an excessive sweating localized in certain body regions. Studies suggest that this condition, affecting between 1% and 3% of the US population, seems to have a genetic predisposition in about two thirds of those affected.

The Minor test, described by Victor Minor in 1928, is a qualitative medical test that is used to evaluate sudomotor function.

Aluminum chloride hexahydrate, sold under the brand name Hydrosal Gel among others, is a first-line treatment for excessive sweating.

<span class="mw-page-title-main">Sofpironium bromide</span> Chemical compound

Sofpironium bromide is a drug used to treat hyperhidrosis. It was approved in Japan in 2020 as a 5% gel for the treatment of primary axillary hyperhidrosis (PAH).

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  42. 1 2 Yano, Motoki; Kiriyama, Masanobu; Fukai, Ichiro; Sasaki, Hidefumi; Kobayashi, Yoshihiro; Mizuno, Kotaro; Haneda, Hiroshi; Suzuki, Eriko; Endo, Katsuhiko; Fujii, Yoshitaka (July 2005). "Endoscopic thoracic sympathectomy for palmar hyperhidrosis: Efficacy of T2 and T3 ganglion resection". Surgery. 138 (1): 40–45. doi:10.1016/j.surg.2005.03.026. PMID   16003315.
  43. ↑ Boscardim, Paulo César Buffara; Oliveira, Ramon Antunes de; Oliveira, Allan Augusto Ferrari Ramos de; Souza, Juliano Mendes de; Carvalho, Roberto Gomes de (February 2011). "Simpatectomia torácica ao nível de 4ª e 5ª costelas para o tratamento de hiper-hidrose axilar" [Thoracic sympathectomy at the level of the fourth and fifth ribs for the treatment of axillary hyperhidrosis]. Jornal Brasileiro de Pneumologia (in Portuguese). 37 (1): 6–12. doi: 10.1590/s1806-37132011000100003 . PMID   21390426.
  44. ↑ Kopelman, Doron; Assalia, Ahmad; Ehrenreich, Marina; Ben-Amnon, Yuval; Bahous, Hany; Hashmonai, Moshe (10 December 2000). "The Effect of Upper Dorsal Thoracoscopic Sympathectomy on the Total Amount of Body Perspiration". Surgery Today. 30 (12): 1089–1092. doi:10.1007/s005950070006. PMID   11193740. S2CID   23980585.
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