Hyperhidrosis overview

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[3]


Overview

Primary hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature. There is controversy regarding the definition of hyperhidrosis, because any sweat that drips off of the body is in excess of that required for thermoregulation. Almost all people will drip sweat off of the body during heavy exercise.

Historical Perspective

  • In 2006, gene mutations were first identified in the pathogenesis of focal hyperhidrosis. [1]
  • In 1950, medical therapy using antimuscarinic agents was developed by Grimson, et al to treat hyperhidrosis.[2]

Classification

  • Primary hyperhidrosis must be distinguished from secondary hyperhidrosis, which can start at any point in life. For some, it can seem to come on unexpectedly. The latter form may be due to a disorder of the thyroid or pituitary gland, diabetes mellitus, tumors, gout, menopause, certain drugs, or mercury poisoning[3]. Such secondary forms may have more serious consequences than just hyperhidrosis, making medical consultation advisable.
  • Hyperhidrosis can also be classified as focal or generalised.
  • Focal hyperhidrosis is most commonly seen during emotional outbursts like sweating of palms, axillae, face etc. Generalised hyperhidrosis affects the entire body and can be triggered by emotion or exertion/heat for thermoregulation.

Pathophysiology

  • Primary hyperhidrosis affects about 0.6-0.1% of the general population.
  • Onset of symptoms occurs during puberty, seen as excess sweating of face, palms, soles and axillae, and symptoms usually resolve with age. [4]

Physiology

  • Sweat is a hypotonic solution produced by eccrine glands and apocrine glands which are distributed all over the body.
  • Most of the body's sweat is produced by the eccrine glands. Eccrine glands have the highest concentration in the axillae. These glands play an important role in thermoregulation. [5]
  • Apocrine sweat glands are seen in the axillae and urogenital region. [6]
  • Sweating is caused by two broad impulses- thermoregulation and emotion. The thermoregulatory centre of sweating is located in the hypothalamus and is triggered by increased body temperature (eg., fever) and the emotion centre of sweating is located in the limbic system and is triggered by extreme emotional states like anxiety, fear etc.[7]

Pathology

  • It is not known what causes primary hyperhidrosis. One theory is that hyperhidrosis results from an overactive sympathetic nervous system, but this hyperactivity may in turn be caused by abnormal brain function. [8]
  • Some patients afflicted with the condition experience a certain degree of reduction in their quality of life, depending on how severe their condition is. [9]
  • Sufferers feel at a loss of control because perspiration takes place independent of temperature and emotional state. However, anxiety can exacerbate the situation for many sufferers. A common complaint of patients is that they get nervous because they sweat, then sweat more because they are nervous.
  • Other factors can play a role; certain foods & drinks, nicotine[10], caffeine, and smells can trigger a response (see also diaphoresis).
  • Primary focal hyperhidrosis is the most common type and is seen during puberty in the axillae and face. [11]
  • Secondary focal hyperhidrosis is a disorder of defective thermoregulation and is seen in neuropathy affecting peripheral nerves like diabetic neuropathy[12], spinal cord disease[13] etc.
  • Generalised primary and secondary hyperhidrosis involve the whole body. Secondary general hyperhidrosis is seen in disorders of thermoregulation like fever, hyperthyroidism etc. [14]
  • Some forms of primary hyperhidrosis are genetically transmitted in either autosomal dominant or recessive pattern.[15]

Causes

Primary focal hyperhidrosis Secondary focal hyperhidrosis Secondary general hyperhidrosis
Puberty Neuropathy Thyrotoxicosis
Social stress Complex regional pain syndrome[19]

Clinical features

  • Excess sweating involving face, axillae, palms and soles
  • Sweating usually causes social embarrassment and impairs social activities. [20]

Differential diagnosis

Epidemiology and demographics

  • The prevalence of hyperhidrosis is around 3% of the general population. [25]
  • It affects men and women equally.
  • There is no racial predilection for hyperhidrosis.

Risk factors

  • There are no known risk factors for hyperhidrosis.

Natural History, Complications and Prognosis

  • Most cases of focal hyperhidrosis are seen during puberty in teenagers.
  • Early clinical manifestations include facial and axillary sweating.
  • Common complications of hyperhidrosis include athlete's foot and pitted keratolysis.[26]
  • Prognosis is generally good with medical, topical or surgical therapy, but patients generally suffer from embarrassment, anxiety or depression due to their condition.[27]

Diagnosis

Diagnostic criteria

The diagnosis of hyperhidrosis is made when the following diagnostic criteria are met. [28]

  • Sweating involving face, axillae, palms and soles for 6 months or longer.
  • No episodes of nocturnal sweating.
  • Episodes of excess sweating which occur at least once per week.
  • Sweating is symmetrical and bilateral.
  • Onset of symptoms at age<25 years.
  • Sweating impairs activities of daily life.
  • Positive family history of hyperhidrosis.

History and Symptoms

  • Hyperhidrosis can either be generalized or localized to specific parts of the body.
  • Hands, feet, axillae, and the groin area are among the most active regions of perspiration due to the relatively high concentration of sweat glands; however, any part of the body may be affected.
  • Patients often feel embarrassed in social situations because situations like shaking hands is difficult for people with sweaty palms.
  • Patients also reports a degree of disability in writing or holding objects.

Laboratory Findings

The following are diagnostic tools used to diagnose hyperhidrosis.

  • Iodine starch test is the most common initial diagnostic tool used to diagnose hyperhidrosis. To perform the test, iodine is applied to the affected skin and starch powder is applied over it. If there is sweat on the skin, the starch and iodine react and a violet colour is seen. This test is helpful to identify focal hyperhidrosis. [29]
  • The amount of sweat can be quantified by using quantitative sudometry. This test stimulates sweat production with acetylcholine electrophoresis. The sweat produced is detected by passing dehumidified nitrogen gas over the required area of skin enclosed in a chamber. The humidity and perspiration is then plotted on a chart and compared.[30]
  • Gravimetry is another method to diagnose hyperhidrosis. Filter paper is applied over affected areas (palms, soles, axillae) and after a defined period of time weight of filter paper before and after is measured[31]. Hyperhidrosis is diagnosed as axillary sweating of >136 mg/min/m2, palmar sweating sweating of >50 mg/min/m2.

Imaging Findings

  • There are no imaging findings associated with hyperhidrosis.

Treatment

  • Hyperhidrosis can usually be very effectively controlled, but there is no known permanent cure because little is known about the cause behind excessive sweating.
  • Treatment for hyperhidrosis consists of local therapies, surgical options and pharmacological therapy.

Medical Therapy

Local therapy options

  • Over the counter antiperspirants containing aluminium chloride. [32]
  • Botulinum injections. Botulinum toxin type A has been shown to be effective in treating plantar hyperhidrosis. [33]
  • Microwave ablation has been shown to have longer lasting antiperspirant effect in axillary focal hyperhidrosis. [34]
  • Tap water iontophersis is used for palmar and plantar hyperhidrosis.[35]
  • Gustatory hyperhidrosis is treated with glycopyrrolate.[36]

Pharmacological therapy options

Surgical therapy

Prevention

  • There are no primary preventive measures for hyperhidrosis.

References

  1. ↑ Higashimoto I, Yoshiura K, Hirakawa N, Higashimoto K, Soejima H, Totoki T; et al. (2006). "Primary palmar hyperhidrosis locus maps to 14q11.2-q13". Am J Med Genet A. 140 (6): 567–72. doi:10.1002/ajmg.a.31127. PMID 16470694.
  2. ↑ GRIMSON KS, LYONS CK, WATKINS WT, CALLAWAY JL (1950). "Successful treatment of hyperhidrosis using banthine". J Am Med Assoc. 143 (15): 1331–2. doi:10.1001/jama.1950.82910500011007. PMID 15428263.
  3. ↑ Schlereth T, Dieterich M, Birklein F (2009). "Hyperhidrosis--causes and treatment of enhanced sweating". Dtsch Arztebl Int. 106 (3): 32–7. doi:10.3238/arztebl.2009.0032. PMC 2695293. PMID 19564960.
  4. ↑ Vlahovic TC (2016). "Plantar Hyperhidrosis: An Overview". Clin Podiatr Med Surg. 33 (3): 441–51. doi:10.1016/j.cpm.2016.02.010. PMID 27215162.
  5. ↑ Sato K, Kang WH, Saga K, Sato KT (1989). "Biology of sweat glands and their disorders. I. Normal sweat gland function". J Am Acad Dermatol. 20 (4): 537–63. doi:10.1016/s0190-9622(89)70063-3. PMID 2654204.
  6. ↑ Sato K, Leidal R, Sato F (1987). "Morphology and development of an apoeccrine sweat gland in human axillae". Am J Physiol. 252 (1 Pt 2): R166–80. doi:10.1152/ajpregu.1987.252.1.R166. PMID 3812728.
  7. ↑ Davidson JR, Foa EB, Connor KM, Churchill LE (2002). "Hyperhidrosis in social anxiety disorder". Prog Neuropsychopharmacol Biol Psychiatry. 26 (7–8): 1327–31. doi:10.1016/s0278-5846(02)00297-x. PMID 12502021.
  8. ↑ <ref name="pmid22150061">Fernandez-Ortega JF, Prieto-Palomino MA, Garcia-Caballero M, Galeas-Lopez JL, Quesada-Garcia G, Baguley IJ (2012). "Paroxysmal sympathetic hyperactivity after traumatic brain injury: clinical and prognostic implications". J Neurotrauma. 29 (7): 1364–70. doi:10.1089/neu.2011.2033. PMID 22150061.
  9. ↑ <ref name="pmid30589248">Lenefsky M, Rice ZP (2018). "Hyperhidrosis and its impact on those living with it". Am J Manag Care. 24 (23 Suppl): S491–S495. PMID 30589248.
  10. ↑ Molin S, Ruzicka T, Herzinger T (2015). "Smoking is associated with combined allergic and irritant hand eczema, contact allergies and hyperhidrosis". J Eur Acad Dermatol Venereol. 29 (12): 2483–6. doi:10.1111/jdv.12846. PMID 25405274.
  11. ↑ <ref name="pmid15280843">Strutton DR, Kowalski JW, Glaser DA, Stang PE (2004). "US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey". J Am Acad Dermatol. 51 (2): 241–8. doi:10.1016/j.jaad.2003.12.040. PMID 15280843.
  12. ↑ <ref name="pmid30859595">Amano M, Namiki T, Munetsugu T, Nakamura M, Hashimoto T, Fujimoto T; et al. (2019). "Dyshidrosis associated with diabetes mellitus: Hypohidrosis associated with diabetic neuropathy and compensated hyperhidrosis". J Dermatol. 46 (8): e292–e293. doi:10.1111/1346-8138.14840. PMID 30859595.
  13. ↑ <ref name="pmid19222501">Kocyigit P, Akay BN, Saral S, Akbostanci C, Bostanci S (2009). "Unilateral hyperhidrosis with accompanying contralateral anhidrosis". Clin Exp Dermatol. 34 (8): e544–6. doi:10.1111/j.1365-2230.2008.03070.x. PMID 19222501.
  14. ↑ <ref name="pmid30710604">Nawrocki S, Cha J (2019). "The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Etiology and clinical work-up". J Am Acad Dermatol. 81 (3): 657–666. doi:10.1016/j.jaad.2018.12.071. PMID 30710604.
  15. ↑ Henning MA, Pedersen OB, Jemec GB (2019). "Genetic disposition to primary hyperhidrosis: a review of literature". Arch Dermatol Res. 311 (10): 735–740. doi:10.1007/s00403-019-01966-1. PMID 31435740.
  16. ↑ <ref name="pmid15280843">Strutton DR, Kowalski JW, Glaser DA, Stang PE (2004). "US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey". J Am Acad Dermatol. 51 (2): 241–8. doi:10.1016/j.jaad.2003.12.040. PMID 15280843.
  17. ↑ Norcliffe-Kaufmann L, Kaufmann H (2012). "Familial dysautonomia (Riley-Day syndrome): when baroreceptor feedback fails". Auton Neurosci. 172 (1–2): 26–30. doi:10.1016/j.autneu.2012.10.012. PMID 23178195.
  18. ↑ <ref name="pmid18557586">Shargall Y, Spratt E, Zeldin RA (2008). "Hyperhidrosis: what is it and why does it occur?". Thorac Surg Clin. 18 (2): 125–32, v. doi:10.1016/j.thorsurg.2008.01.001. PMID 18557586.
  19. ↑ <ref name="pmid32174618">Alkali NH, Al-Tahan AM, Al-Majed M, Al-Tahan H (2020). "Complex regional pain syndrome: A case report and review of the literature". Ann Afr Med. 19 (1): 68–70. doi:10.4103/aam.aam_23_19. PMC 7189882 Check |pmc= value (help). PMID 32174618 Check |pmid= value (help).
  20. ↑ Lenefsky M, Rice ZP (2018). "Hyperhidrosis and its impact on those living with it". Am J Manag Care. 24 (23 Suppl): S491–S495. PMID 30589248.
  21. ↑ Huguet I, Grossman A (2017). "MANAGEMENT OF ENDOCRINE DISEASE: Flushing: current concepts". Eur J Endocrinol. 177 (5): R219–R229. doi:10.1530/EJE-17-0295. PMID 28982960.
  22. ↑ Yamada S, Ito Y, Nishijima S, Kadekawa K, Sugaya K (2018). "Basic and clinical aspects of antimuscarinic agents used to treat overactive bladder". Pharmacol Ther. 189: 130–148. doi:10.1016/j.pharmthera.2018.04.010. PMID 29709423.
  23. ↑ Shin J, Jang YH, Kim SC, Kim YC (2013). "Eccrine angiomatous hamartoma: a review of ten cases". Ann Dermatol. 25 (2): 208–12. doi:10.5021/ad.2013.25.2.208. PMC 3662915. PMID 23717013.
  24. ↑ Motz KM, Kim YJ (2016). "Auriculotemporal Syndrome (Frey Syndrome)". Otolaryngol Clin North Am. 49 (2): 501–9. doi:10.1016/j.otc.2015.10.010. PMC 5457802. PMID 26902982.
  25. ↑ Romero FR, Haddad GR, Miot HA, Cataneo DC (2016). "Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects". An Bras Dermatol. 91 (6): 716–725. doi:10.1590/abd1806-4841.20165358. PMC 5193180. PMID 28099590.
  26. ↑ Balić A, Bukvić Mokos Z, Marinović B, Ledić Drvar D (2018). "Tatami Mats: A Source of Pitted Keratolysis in a Martial Arts Athlete?". Acta Dermatovenerol Croat. 26 (1): 68–70. PMID 29782305.
  27. ↑ Mirkovic SE, Rystedt A, Balling M, Swartling C (2018). "Hyperhidrosis Substantially Reduces Quality of Life in Children: A Retrospective Study Describing Symptoms, Consequences and Treatment with Botulinum Toxin". Acta Derm Venereol. 98 (1): 103–107. doi:10.2340/00015555-2755. PMID 28761964.
  28. ↑ Wohlrab J, Kreft B (2018). "[Hyperhidrosis-aetiopathogenesis, diagnosis, clinical symptoms and treatment]". Hautarzt. 69 (10): 857–869. doi:10.1007/s00105-018-4265-8. PMID 30218113.
  29. ↑ Hansen C, Wayment B, Klein S, Godfrey B (2018). "Iodine-Starch test for assessment of hyperhidrosis in amputees, evaluation of different methods of application". Disabil Rehabil. 40 (25): 3076–3080. doi:10.1080/09638288.2017.1367965. PMID 28826272.
  30. ↑ Low PA, Caskey PE, Tuck RR, Fealey RD, Dyck PJ (1983). "Quantitative sudomotor axon reflex test in normal and neuropathic subjects". Ann Neurol. 14 (5): 573–80. doi:10.1002/ana.410140513. PMID 6316835.
  31. ↑ Stefaniak TJ, Proczko M (2013). "Gravimetry in sweating assessment in primary hyperhidrosis and healthy individuals". Clin Auton Res. 23 (4): 197–200. doi:10.1007/s10286-013-0201-2. PMC 3735961. PMID 23761115.
  32. ↑ Swaile DF, Elstun LT, Benzing KW (2012). "Clinical studies of sweat rate reduction by an over-the-counter soft-solid antiperspirant and comparison with a prescription antiperspirant product in male panelists". Br J Dermatol. 166 Suppl 1: 22–6. doi:10.1111/j.1365-2133.2011.10786.x. PMID 22385032.
  33. ↑ Bernhard MK, Krause M, Syrbe S (2018). "Sweaty feet in adolescents-Early use of botulinum type A toxin in juvenile plantar hyperhidrosis". Pediatr Dermatol. 35 (6): 784–786. doi:10.1111/pde.13628. PMID 30178509.
  34. ↑ Nasr MW, Jabbour SF, Haber RN, Kechichian EG, El Hachem L (2017). "Comparison of microwave ablation, botulinum toxin injection, and liposuction-curettage in the treatment of axillary hyperhidrosis: A systematic review". J Cosmet Laser Ther. 19 (1): 36–42. doi:10.1080/14764172.2016.1248438. PMID 27782761.
  35. ↑ Dagash H, McCaffrey S, Mellor K, Roycroft A, Helbling I (2017). "Tap water iontophoresis in the treatment of pediatric hyperhidrosis". J Pediatr Surg. 52 (2): 309–312. doi:10.1016/j.jpedsurg.2016.11.026. PMID 27912978.
  36. ↑ Kim WO, Kil HK, Yoon DM, Cho MJ (2003). "Treatment of compensatory gustatory hyperhidrosis with topical glycopyrrolate". Yonsei Med J. 44 (4): 579–82. doi:10.3349/ymj.2003.44.4.579. PMID 12950111.
  37. ↑ Delort S, Marchi E, Corrêa MA (2017). "Oxybutynin as an alternative treatment for hyperhidrosis". An Bras Dermatol. 92 (2): 217–220. doi:10.1590/abd1806-4841.201755126. PMC 5429108. PMID 28538882.
  38. ↑ Goldstein DS, Pechnik S, Moak J, Eldadah B (2004). "Painful sweating". Neurology. 63 (8): 1471–5. doi:10.1212/01.wnl.0000142037.06255.a8. PMID 15505167.
  39. ↑ Cheshire WP, Fealey RD (2008). "Drug-induced hyperhidrosis and hypohidrosis: incidence, prevention and management". Drug Saf. 31 (2): 109–26. doi:10.2165/00002018-200831020-00002. PMID 18217788.
  40. ↑ Lee D, Cho SH, Kim YC, Park JH, Lee SS, Park SW (2006). "Tumescent liposuction with dermal curettage for treatment of axillary osmidrosis and hyperhidrosis". Dermatol Surg. 32 (4): 505–11, discussion 511. doi:10.1111/j.1524-4725.2006.32103.x. PMID 16681657.
  41. ↑ Yuncu G, Turk F, Ozturk G, Atinkaya C (2013). "Comparison of only T3 and T3-T4 sympathectomy for axillary hyperhidrosis regarding treatment effect and compensatory sweating". Interact Cardiovasc Thorac Surg. 17 (2): 263–7. doi:10.1093/icvts/ivt160. PMC 3715172. PMID 23644731.

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