Hyperhidrosis

Hyperhidrosis can be focal or generalized.

Sweating is often present during examination and sometimes is extreme. Clothing can be soaked, and palms or soles may become macerated and fissured.

Hyperhidrosis can cause emotional distress to patients and may lead to social withdrawal. Palmar or plantar skin may appear pale.

Hyperhidrosis can be primary or secondary to an underlying medical condition. It is diagnosed by history and examination but can be confirmed with the iodine and starch test. For this test, iodine solution is applied to the affected area and allowed to dry. Cornstarch is then dusted on the area, which makes areas of sweating appear dark. Testing is necessary only to confirm foci of sweating (as in Frey syndrome, or to locate the area needing surgical or botulinum toxin treatment Treatment ) or in a semiquantitative way when following the course of treatment. Asymmetry in the pattern of sweating suggests a neurologic cause.

Laboratory tests to identify a cause of hyperhidrosis are guided by the patient's other symptoms and might include, for example, complete blood count to detect leukemia Overview of Leukemia Leukemia is a malignant condition involving the excess production of immature or abnormal leukocytes, which eventually suppresses the production of normal blood cells and results in symptoms... read more , serum glucose to detect diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , and thyroid-stimulating hormone to screen for thyroid dysfunction.

Initial treatment of focal and generalized sweating is similar.

Aluminum chloride hexahydrate (an antiperspirant) 6 to 20% solution in absolute ethyl alcohol is indicated for topical treatment of axillary, palmar, and plantar sweating; these preparations require a prescription. The solution precipitates salts, which block sweat ducts. It is most effective when applied nightly and should be washed off in the morning. Sometimes an anticholinergic drug is taken before applying to prevent sweat from washing the aluminum chloride away. Initially, several applications weekly are needed to achieve control, then a maintenance schedule of once or twice a week is followed. If treatment under occlusion is irritating, it should be tried without occlusion. This solution should not be applied to inflamed, broken, wet, or recently shaved skin. High-concentration, water-based aluminum chloride solutions may provide adequate relief in milder cases.

Glycopyrronium tosylate (an anticholinergic drug) 2.4% cloth wipes can be used to treat primary axillary hyperhidrosis in people 9 years of age and older (1 Treatment reference Hyperhidrosis is excessive sweating, which can be focal or diffuse and has multiple causes. Sweating of the axillae, palms, and soles is most often a normal response due to stress, exercise... read more ). Caution should be used in patients who are sensitive to anticholinergic drug effects.

Tap-water iontophoresis, in which salt ions are introduced into the skin using electric current, is an option for patients unresponsive to topical treatments. The affected areas (typically palms or soles) are placed in tap-water basins each containing an electrode across which a 15- to 25-mA current is applied for 10 to 20 minutes. This routine is done daily for 1 week and then repeated weekly or bimonthly. Iontophoresis may be made more effective by dissolving anticholinergic tablets (eg, glycopyrrolate) into the water of the iontophoresis basins. Although the treatments are usually effective, the technique is time-consuming and somewhat cumbersome, and some patients tire of the routine.

Oral anticholinergic drugs may help some patients. Glycopyrrolate or oxybutynin can be used to decrease sweating but can be limited by anticholinergic adverse effects, including dry mouth, dry skin, flushing, blurred vision, urinary retention Urinary Retention Urinary retention is incomplete emptying of the bladder or cessation of urination. Urinary retention may be Acute Chronic Causes include impaired bladder contractility, bladder outlet obstruction... read more , mydriasis, and cardiac arrhythmias Overview of Arrhythmias The normal heart beats in a regular, coordinated way because electrical impulses generated and spread by myocytes with unique electrical properties trigger a sequence of organized myocardial... read more .

Oral clonidine is an alpha-2-adrenergic agonist that decreases sweating mediated by sympathetic nervous system activity.

Botulinum toxin type A is a neurotoxin that decreases the release of acetylcholine from sympathetic nerves serving eccrine glands. Injected directly into the axillae, palms, or forehead, botulinum toxin inhibits sweating for about 5 months depending on dose. Of note, botulinum toxin is approved by the U.S. Food and Drug Administration only for axillary hyperhidrosis and may not be covered by insurance for other sites of hyperhidrosis. Complications include local muscle weakness and headache. Injections are effective but painful and expensive, and treatment must be repeated 2 to 3 times per year.

A microwave-based devicecan heat and subsequently permanently destroy sweat glands. Patients may benefit from two treatments at least 3 months apart.

Surgery is indicated if more conservative treatments fail. Patients with axillary sweating can be treated with surgical excision of axillary sweat glands through open dissection or by liposuction (the latter appears to have lower morbidity). Patients with palmar sweating can be treated with endoscopic transthoracic sympathectomy. The potential morbidity of surgery must be considered, especially in sympathectomy. Potential complications include phantom sweating (a sensation of sweating in the absence of sweating), compensatory hyperhidrosis (increased sweating in untreated parts of the body), gustatory sweating, neuralgia, and Horner syndrome Horner Syndrome Horner syndrome is ptosis, miosis, and anhidrosis due to dysfunction of cervical sympathetic output. (See also Overview of the Autonomic Nervous System.) Horner syndrome results when the cervical... read more . Compensatory hyperhidrosis is most common after endoscopic transthoracic sympathectomy, developing in up to 80% of patients, and can be disabling and far worse than the original problem.