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AlexanderSalava

Excessive Sweating (Hyperhidrosis)

Essentials

  • Hyperhidrosis may be local (e.g. palms and soles, underarms, head) or generalized. It may cause the patient psychosocial suffering and impaired performance.
  • In its localized form, hyperhidrosis is an idiopathic condition that usually starts in adolescence already.
  • Menopausal symptoms, i.e. hot flushes, erythema and sweating in the head, neck and/or chest area, should be recognized.
  • Generalized hyperhidrosis of sudden onset may have secondary causes (metabolic disease, infection, medication).
  • Treatment should focus on the cause of hyperhidrosis, and symptomatic treatment should be started as necessary.

Aetiology

The most common causes

  • Idiopathic hyperhidrosis (palms and soles, underarms, head)
    • This type of hyperhidrosis is due to dysregulation of the autonomic nervous system, leading to more profuse sweating than is normal, unrelated to the thermoregulation of the body.
    • The border between idiopathic hyperhidrosis usually beginning in adolescence and normal sweating is indistinct and also depends on heredity.
  • Physiological causes: emotional reaction, physical stress, hot environment, spicy food, alcohol (alcoholism), illegal drugs, coffee and tea
  • Menopause: hot flushes, i.e. repeated short episodes with excessive sweating and erythema of the head, neck and/or chest
  • Rosacea Rosacea: blotchy erythema and sweating of the face with sudden onset (flush) is a common primary symptom of rosacea.

Possible secondary causes

Symptoms

  • Visible sweating that may in some cases be accompanied by erythema of the skin. The skin is moist and often cold.

Diagnosis

  • Careful history taking and clinical examination are usually sufficient for diagnosis.

History

  • Is the excessive sweating local or generalized?
    • Idiopathic hyperhidrosis manifests itself mainly in the underarms, on palms and soles and in the head area. It is local and symmetric, often beginning in childhood or adolescence, the tendency to hyperhidrosis is hereditary, and the patient is otherwise healthy.
    • Asymmetric local hyperhidrosis may suggest a neurological cause (such as nerve damage due to a tumour or other cause or neuropathy).
  • Did excessive sweating start suddenly, is it a new symptom?
    • Generalized hyperhidrosis as a new symptom may have secondary causes. If so, it is usually not the only symptom.
  • Are there other skin symptoms?
  • Medication

Examination

  • Careful clinical examination, including blood pressure, palpation of the thyroid gland, palpation of lymph nodes, auscultation of the lungs and the heart, neurological status, hand tremor
  • Is there clinical evidence of a secondary cause?
    • General symptoms, such as fever, tachycardia, fatigue, impaired general status, increased thirst, diarrhoea, respiratory symptoms, weight loss or nocturnal sweating may suggest a secondary cause.
  • If sweating is the only symptom, there is rarely any underlying endocrinological disease.
  • Assessment of the patient's psychosocial status is important. Fear, anxiety or panic symptoms may suggest a psychiatric cause.

Investigations

  • More specific further examinations should be performed only if secondary causes are suspected based on history and clinical examination (and there are other symptoms besides sweating) or if the symptoms grow progressively worse.
  • Menopausal symptoms
    • If a woman is under 45 years old and has symptoms, it may be warranted to check whether she is going through menopause. A serum FSH determination may help in the differential diagnosis (> 30 IU/l indicates a decline in ovarian function and consequent oestrogen deficiency) Menopausal Symptoms and Hormone Therapy.

Treatment

Local (idiopathic) hyperhidrosis

  • Topical antiperspirants containing aluminum salts (solution, spray, roll-on, etc.) http://www.dynamed.com/condition/hyperhidrosis#TOPICAL_ALUMINUM_SALTS
    • Should first be applied once every evening for a few weeks, and the frequency can then be reduced to once or twice a week, for example.
    • These are most effective for underarm sweating but are also worth trying for the palms, soles and other areas.
    • An extemporaneously prepared medicine containing aluminium chloride hexahydrate solution 20% to be applied on skin may be prescribed. It is more effective than over-the-counter products. Follow local regulations regarding extemporaneous preparations. In some countries, this may be available as a ready-made product (e.g. Drysol® ).
  • Topical anticholinergic (glycopyrronium cream)
    • Initially once daily in the evening for 4 weeks, then the use can be reduced to e.g. twice a week.
  • Water iontophoresis http://www.dynamed.com/condition/hyperhidrosis#IONTOPHORESIS
    • Can be used for the treatment of palmar and plantar hyperhidrosis. The treatment is available in the dermatology units of certain university and central hospitals, as well as in the private sector (dermatologists, chiropodists). Treatment can first be given daily for 2 weeks.
    • Response varies individually.
    • A minimum trial of 10 therapy sessions is recommended.
    • The required weekly amount of maintenance therapy varies individually. If the treatment proves useful, the patient can purchase the required equipment for use at home.
  • Botulin injections http://www.dynamed.com/condition/hyperhidrosis#BOTULINUM_TOXIN_INJECTIONS are effective for hyperhidrosis of the underarms, palms and soles. Injections are given every 6 to 12 months.
    • Botulin injections are used for the treatment of severe hyperhidrosis.
    • Treatment can be started in the dermatological units of certain university and central hospitals but maintenance therapy is usually given in the private sector (dermatologists).
    • Botulinum toxin A is injected intradermally, 2 units about 1.5 cm apart.
      • Before treatment, areas with hyperhidrosis can be localized by performing a sweat test (Minor's starch-iodine test): 5% iodine tincture is applied to the sweating skin. Starch (e.g. potato flour) is then spread on the area. The sweating places are immediately stained black.
    • 100 units are usually sufficient to treat the underarms. About 200 units are most often needed to treat palms and soles. Botulin is not as effective in plantar hyperhidrosis as in the other indications.
    • Underarms can be treated without local anaesthesia. To treat palms, nerve block anaesthesia must normally be used or the injection sites frozen using a liquid nitrogen cryoprobe, which is effective in alleviating pain at the puncture site.
  • Systemic anticholinergic drugs http://www.dynamed.com/condition/hyperhidrosis#SYSTEMIC_MEDICATIONS, e.g. oxybutynin (see below), have been used also in local hyperhidrosis as symptomatic medication to be taken when needed or as long-term therapy.
  • In severe cases, surgical treatment, such as excision of sudoriferous glands in the underarms, laser or radiofrequency therapy or transthoracic sympathectomy, has been used.

Generalized hyperhidrosis

  • First of all, any secondary causes should be treated and factors that the patient has found to exacerbate sweating should be avoided.
  • Hormone replacement therapy is effective against menopausal hot flushes Menopausal Symptoms and Hormone Therapy.
  • Patients with fear, anxiety or panic symptoms may benefit from antidepressants. Selective serotonin reuptake inhibitors (SSRI), such as paroxetine or fluoxetine, may paradoxically reduce hyperhidrosis (in some cases hyperhidrosis can be an adverse effect).
  • In severe cases, systemic anticholinergic drugs can be tried. The dose should be gradually increased until symptoms disappear.
    • For example, 2.5-5.0 mg oxybutynin, as necessary, before a situation provoking sweating or as long-term treatment (in the first week, 2.5 mg every night, in the following 2 weeks 2.5 mg twice daily, and subsequently 5 mg once or twice daily).
    • Before sweating can be sufficiently prevented by anticholinergic drugs, patients may experience disturbing dryness of the mouth, and accommodation, urinary and intestinal problems. In such a situation, the treatment must be discontinued or dose reduced.

Consultation

  • A dermatologist should be consulted in cases of severe hyperhidrosis.
  • If a secondary cause is found, an appropriate specialist should be consulted for its treatment.
  • A psychiatrist should be consulted in severe psychiatric cases.

References

  • Wong NS, Adlam TM, Potts GA et al. Hyperhidrosis: A Review of Recent Advances in Treatment with Topical Anticholinergics. Dermatol Ther (Heidelb) 2022;12(12):2705-2714.[PubMed]
  • Henning MAS, Bouazzi D, Jemec GBE. Treatment of Hyperhidrosis: An Update. Am J Clin Dermatol 2022;23(5):635-646. [PubMed]
  • Arora G, Kassir M, Patil A et al. Treatment of Axillary hyperhidrosis. J Cosmet Dermatol 2022;21(1):62-70.[PubMed]
  • Stuart ME, Strite SA, Gillard KK. A systematic evidence-based review of treatments for primary hyperhidrosis. J Drug Assess 2020;10(1):35-50. [PubMed]
  • Wade R, Llewellyn A, Jones-Diette J et al. Interventional management of hyperhidrosis in secondary care: a systematic review. Br J Dermatol 2018;179(3):599-608. [PubMed]
  • Beyer C, Cappetta K, Johnson JA et al. Meta-analysis: Risk of hyperhidrosis with second-generation antidepressants. Depress Anxiety 2017;Sep 7. doi: 10.1002/da.22680 [PubMed]
  • Schollhammer M, Brenaut E, Menard-Andivot N et al. Oxybutynin as a treatment for generalized hyperhidrosis: a randomized, placebo-controlled trial. Br J Dermatol 2015;173(5):1163-8. [PubMed]
  • Wolosker N, Teivelis MP, Krutman M et al. Long-term results of the use of oxybutynin for the treatment of axillary hyperhidrosis. Ann Vasc Surg 2014;28(5):1106-12. [PubMed]
  • Naumann M, Dressler D, Hallett M et al. Evidence-based review and assessment of botulinum neurotoxin for the treatment of secretory disorders. Toxicon 2013;(67):141-52. [PubMed]
  • Benson RA, Palin R, Holt PJ et al. Diagnosis and management of hyperhidrosis. BMJ 2013;(347):f6800. [PubMed]
  • Katshu MZ, Bhattacharya A, Nizamie SH. Efficacy of paroxetine in primary palmoplantar hyperhidrosis occurring with juvenile myoclonic epilepsy. Dermatology 2011;223(3):193-5. [PubMed]
  • Aguilar-Ferrándiz ME, Moreno-Lorenzo C, Matarán-Peñarrocha GA et al. Effects of tap water iontophoresis and psychological techniques on psychosocial aspects of primary palmar hyperhidrosis. Eur J Dermatol 2011;21(2):256-8. [PubMed]
  • Praharaj SK, Arora M. Paroxetine useful for palmar-plantar hyperhidrosis. Ann Pharmacother 2006;40(10):1884-6. [PubMed]
  • Davidson JR, Foa EB, Connor KM et al. Hyperhidrosis in social anxiety disorder. Prog Neuropsychopharmacol Biol Psychiatry 2002;26(7-8):1327-31. [PubMed]