Overview:

• Hyperhidrosis is a disorder of excessive sweating due to the overstimulation of cholinergic receptors on eccrine glands.

• This disorder is characterized by sweating beyond what the body uses for homeostatic temperature regulation.

• Eccrine glands are concentrated in areas such as the axillae, palms, soles, and face; therefore, these are the areas most commonly associated with hyperhidrosis.

• The acetylcholine negative feedback loop is likely impaired in these patients, which may help explain how a physiologic response can become pathologic.

• Studies have shown the prevalence of this disorder to be approximately 3% in the United States. Hyperhidrosis can result in emotional, psychological, social, and occupational impairment.

• Hyperhidrosis is classified as primary and secondary, and the management and treatment can significantly differ for each.

• The primary disease typically presents earlier in life with more localized symptoms. The secondary disease typically presents due to adverse effects of medications or systemic disorders, particularly neurologic.

• The diagnosis most often is made clinically, and grading scales and tests are available to assist in determining the severity and localization.

• Laboratory workup may be indicated if a secondary cause is suspected to rule out infection, hyperthyroidism, diabetes mellitus, neurologic disorder, or a medication side-effect.

• There are several treatment options for hyperhidrosis, including topical aluminum chloride and oral anticholinergic medications, which are sufficient in patients with mild to moderate disease.

• Botulinum toxin A injections, sympathectomy, and local excision are also effective but reserved for patients that are resistant to conservative therapy.

• Excessive sweating or HYPERHIDROSIS  which can be localized or generalized, predominantly noted in the axilla, groin, or palms of hands and soles of feet. 

Etiology

• Hyperhidrosis can be categorized as either primary or secondary. This distinction is important to make because treatment and management may significantly differ between the two groups. The etiology of primary hyperhidrosis remains unknown despite multiple literature reviews.

• Genetic factors are believed to play a role in excessive neural stimulation, although this is not well understood.

• Secondary causes are usually easier to identify because they are associated with medications such as dopamine agonists, selective serotonin reuptake inhibitors (SSRIs), antipsychotics, and insulin; systemic disorders such as diabetes mellitus, hyperthyroidism, Parkinson disease, and other neurologic disorders; and tumors such as pheochromocytoma and lymphoma.

• Almost any febrile illness can cause hyperhidrosis.

• Chronic excessive alcohol consumption and tuberculosis are also associated with hyperhidrosis.

• Developing segmental or localized hyperhidrosis is rare.

• The condition can present on the forehead, axilla, palm, feet, or forearm in some adults. Some postmenopausal women develop moderate to severe hyperhidrosis around their face and scalp.

• Unilateral hyperhidrosis tends to be more common on the right side of the face or arm, with anhidrosis on the left side.

Select your actual symptoms:

• Excessive sweating for 6 months disrupts life.

• You suddenly begin to sweat more than usual.

• You experience night sweats for no apparent reason.

• Axillae (armpits), Groin, or palms of hands or soles of feet.

Pharmacology treatments if recommended.

• Aluminum chloride hexahydrate. (irritates skin).

• Oxybutynin oral medication.

• Qbrexza, expensive clothes for axillae (armpits).

• See your doctor for botox injections.

• Iontophoresis (an electrical current therapy, see your doctor…)

 (I DON’T OFFER ANY ELECTRICAL THERAPY OR INJECTIONS).

 

EVALUATION AND MORE IN DEPTH TREATMENTS AND MANAGEMENT.

Evaluation

• It is important to first determine whether the source is primary or secondary, and a thorough history will help differentiate. If a secondary cause is suspected, providers should consider ordering a complete blood count, basic metabolic panel, thyroid-stimulating hormone, sedimentation rate, antinuclear antibody, hemoglobin A1C, and chest x-ray.

• These tests will assist in ruling out infection, kidney dysfunction, malignancy, diabetes mellitus, thyroid disease, an inflammatory disorder, or connective tissue disease, which can all be associated with hyperhidrosis.

• Providers can also thoroughly evaluate the severity of the disease by assessing the amount of palmar involvement using a measuring scale or determining the disease pattern using a starch-iodine test.

• These are not widely used because visual assessment alone is usually sufficient to make the diagnosis.

Treatment / Management

• Treating hyperhidrosis has become easier for clinicians as more treatment options have become available, and a stepwise approach is often effective. There are many topical and systemic agents available to treat hyperhidrosis.

• First-line therapy for hyperhidrosis includes over-the-counter aluminum chloride hexahydrate 20% for 3 to 4 nights, then nightly as needed. Skin irritation can occur, and patients often become intolerant of it in the long term.

• Recently topical glycopyrronium tosylate (pre moistened cloth containing 2.4% glycopyrronium solution) was approved to treat sweating.

• Axillary sweating can be managed with aluminum chloride gel. While it does work, it is a potent irritant.

• All topical agents can cause skin sensitization, and some, like tannic acid and potassium permanganate, can also cause skin discoloration. These agents appear to decrease sweating by denaturing keratin and thus occluding the pores of the sweat glands. The duration of the effect is very short.

• If a patient does not respond to topical treatment or there are more generalized symptoms, oral anticholinergic medications, including oxybutynin 5 mg to 10 mg per day or topical glycopyrrolate 0.5% to 2.0%, should be considered. Anticholinergic agents can cause dry eyes, dry mouth, urinary retention, and constipation.

• Iontophoresis two to three times weekly and botulinum toxin A injections every 3 to 4 weeks are effective if patients fail topical and oral drug therapy. Iontophoresis is a long-term treatment, and at best, its effects are mild. Many agents can be added to the water, but compliance with this treatment is low.

• Botulinum toxin is effective; however, it is expensive, and repeat treatments are required. Some experts recommend botulinum toxin plus lidocaine for injection into the axilla. Botulinum toxin A acts by cleaving the SNAP-25 protein.

• This prevents the binding and presynaptic fusion of the acetylcholine vesicles with the nerve terminus and thus blocks the release of acetylcholine.

• It is the most appropriate treatment after failing topical antiperspirants and oral anticholinergics. Decreased perspiration can last from 6 to 24 months. Injections are usually performed in both axillae; however, they also can be useful in the palms and soles. These locations are less practical and will likely require local anesthesia to limit discomfort.

• More invasive therapeutic measures are available, including sympathectomy or local excision as a last resort. Many surgical procedures have been developed to manage hyperhidrosis, including sympathectomy, radiofrequency ablation, subcutaneous liposuction, and surgical excision of affected areas.

• Of all these, sympathectomy appears to be the best treatment that is somewhat permanent. It involves excision of the ganglia (T2-T4) responsible for sweating. Resection of T1 ganglia is done for facial sweating, T2 and T3 for palmar sweating, and T4 for axillary sweating. The procedure can be done thoracoscopically, but complications are common. Compensatory sweating, gustatory sweating, Horner syndrome, pneumothorax, pain, and intercostal neuralgia have all been reported.

• If a secondary cause is suspected, treatment of the underlying disorder or discontinuing the suspected medication is recommended in addition to regular therapy.

 

Retrieved from:

https://www.aafp.org/pubs/afp/issues/2018/0601/p729.html

https://www.cdc.gov/disasters/extremeheat/warning.html

https://www.ncbi.nlm.nih.gov/books/NBK459227/#article-23177.s9