Hyperhidrosis (Excessive Sweating)

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What Is Hyperhidrosis?

Hyperhidrosis is sweating in excess of that normally required to regulate the body temperature. Hyperhidrosis can be primary hyperhidrosis without underlying medical conditions associated or it can be secondary to other medical conditions. Primary hyperhidrosis can run in families and usually becomes significant at or somewhat before puberty. Secondary hyperhidrosis can begin at any age.

Hyperhidrosis may be generalized over the entire body or localized to problem areas like the face (cranial facial hyperhidrosis), armpits, or the palms and soles. The severity of hyperhidrosis varies from patient to patient and even the same patient over time.

What Causes Hyperhidrosis?

Primary, or essential, hyperhidrosis is caused by excessive activity of the sweat glands and is associated with overactivity of a branch of the involuntary nervous system (the sympathetic nervous system). Even minor arousal will lead to dramatic, excessive, and usually inappropriate sweating. For many, this is a familial disorder that is genetically inherited in an autosomal dominant inheritance pattern. Primary hyperhidrosis has an occurrence rate as high as 1% in the general population. Most studies report that Japanese have an exceptionally high rate of essential palmoplantar hyperhidrosis, up to twenty times the incidence in other ethnic groups.

Secondary, or acquired, hyperhidrosis is usually generalized and has a variety of causes and presentations. These include metabolic disorders, hormonal changes, medication reactions, neurologic disease, and certain tumors.

What Are Risk Factors for Hyperhidrosis?

For primary axillary or palmoplantar hyperhidrosis, the main risk factor would be other first-order relatives with a similar condition.

Besides febrile illness, the main diseases to be considered for patients with generalized secondary hyperhidrosis are tuberculosis, chronic alcoholism, hyperthyroidism, gout, diabetes, multiple myeloma, and pheochromocytoma. Neurologic diseases such as stroke, tabes dorsalis (syphilis), spinal injury, and Parkinson's disease have also been associated with excessive sweating. Unfortunately, many of the drugs prescribed for Parkinson's disease may also cause hyperhidrosis, including donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon), and tacrine (Cognex).

Other medications associated with generalized secondary hyperhidrosis include antidepressants: monoamine oxidase inhibitors, selective serotonin release inhibitors, and tricyclic antidepressants. Buspirone (BuSpar), trazodone (Oleptro), and most antipsychotic medications have also been reported to cause this. Commonly recommended aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin converting enzyme inhibitors, pentoxifylline (Trental, Pentoxil), amlodipine (Norvasc), and sildenafil (Revatio, Viagra) may also induce hyperhidrosis. Central nervous system stimulants like amphetamines can cause hyperhidrosis as can caffeine, even with casual use.

Patients who are perimenopausal may experience dramatic sweating associated with their "hot flashes."

What Causes You to Sweat? Hidrosis and Hyperhidrosis

What Are Hyperhidrosis Symptoms and Signs?

In primary hyperhidrosis, excessive sweating of the palms, soles, and axillae (armpits) often starts with the first social exposure of the day. Sometimes even the thought of dealing with other people sets off a bout of sweating. It is often calm at night and most likely to be dry when the patient is relaxed and ready for bed.

Acquired hyperhidrosis may be constant through the day, occur in unpredictable paroxysms such as in pheochromocytoma, timed with the peak serum levels of offending medication or as the classic "night sweats" of patients with tuberculosis.

Other conditions related to hyperhidrosis are bromhidrosis (malodorous sweat and skin) and chromhidrosis (colored sweat as by product of bacteria).

Beyond the dampness, hyperhidrosis may significantly impact the overall quality of life of those affected. Anxiety and depression are common in afflicted patients to the extent they may need to be addressed by appropriate specialists as separate, significant health concerns.

How Do Health-Care Professionals Diagnose Hyperhidrosis?

Diagnosis is usually made by history or direct observation of excessive sweating. Many patients with palmar hyperhidrosis will instinctively wipe their hand on their clothing before extending it for a handshake. There are no specific tests for hyperhidrosis, but the starch-iodine test is sometimes used to map out the most actively sweating areas of the armpits prior to treatments with injection of botulinum toxin.

Are There Treatments or Medications for Hyperhidrosis?

The treatment of hyperhidrosis depends upon the location, what has been tried before, and the medical history. If there are hormone, metabolic, or tumor-related causes for acquired hyperhidrosis, these are addressed. If timing suggests a medication is involved, changing the medication to a different class or family may help.

Initial treatment for palmoplantar or axillary hyperhidrosis includes potent antiperspirants, such as 20% aluminum chloride (Drysol, Xerac, Hypercare). This is applied at night when the patient is usually at their most relaxed and the skin will be the driest. Patients may only be able to tolerate this every third or every other night because of the local irritation. Sometimes potent topical antiperspirants are used with other treatments such as iontophoresis. Aluminum chloride also comes as an over-the-counter solution or pads with strengths from 5%-12% (Certain Dri).

If topical therapy for palmoplantar hyperhidrosis is not effective, iontophoresis is a common next step. During iontophoresis, the hands (or feet) are bathed in a pan of water while electric current is passed through it. Standard treatment is 20 minutes for hands, 40 minutes for hands and feet done at least three times weekly. If this is successful, patients can usually enter a maintenance program in which the procedure may be done every one to two weeks. While pads and devices exist for treatment of hyperhidrosis of the armpits, they generally are more difficult there and not as effective as they are for palms and soles.

Botulinum toxin injection (Botox) of the palms and soles is often a next step. Usually attempts to treat topically and/or systemically are required before many health insurance companies will approve botulinum toxin injections. Treatment is expensive because of the volume of medication needed for effective treatment. Treating both armpits will usually involve at least 100 units (1 bottle) and is generally well tolerated. Injecting the hands or feet is very painful and may sometimes require nerve blocks to complete. It may take 100 units per hand or foot. Results last on average about six months, but some patients will be able to last much longer between treatments.

Many patients cannot tolerate the side effects of systemic therapy with anticholinergic oral medications, but for many, they may prove useful as either a maintenance medication or one used for "emergencies" such as major social events where they want to be their driest. Glycopyrrolate (Robinul) is usually effective at suppressing focal or generalized hyperhidrosis, and most patients can find a dose that is effective without having too many side effects (see below). Oxybutynin (Ditropan) is more effective in some patients but generally with more reported side effects.

Other oral medications, such as the calcium channel blockers (like diltiazem [Dilt-CD, Cardizem]), have less sedation but can cause hypotension and are generally not as effective, especially as monotherapy. Clonidine (Catapres) has been helpful in some with hyperhidrosis, especially in those in whom the condition is caused by antidepressants. This can be quite sedating at the doses necessary and should not be stopped suddenly. Topiramate (Topamax) can decrease sweating. It also may stop sweating completely, which can be dangerous in hot climates.

If the worst of the patient's hyperhidrosis is related to public speaking, medications to reduce anxiety, such as lorazepam (Ativan), and beta-blockers, such as propranolol, have proven effective. Combining anti-anxiety medications with anticholinergics may cause oversedation, and beta-blockers may cause abnormally low blood pressure when used in those with normal blood pressure.

Several laser systems as well as other thermal devices, both infrared and microwave, have been reported to help hyperhidrosis. These are not all yet widely available. A variety of laser frequencies have been tried and include NdYAG at 1024 nM as well as diode lasers at 924 and 975 nm.

Surgery

Cervical sympathectomy is one of the fastest effective treatments but also the most expensive and problem prone one. The surgical technique for sympathectomy has evolved over the years from larger open procedures to the endoscopic surgeries being performed now. The level of block depends upon the target symptom. Craniofacial hyperhidrosis is best managed by a T2 level block, palmar hyperhidrosis by T2-T3 block, and axillary with block or destruction of the T4 ganglion. To make a difference with hyperhidrosis of the feet, endoscopic lumbar sympathectomies are being used. Many consider sympathectomy the treatment of choice for severe hyperhidrosis in children since it is immediate after a single treatment performed under general anesthesia rather than a series of painful injections or sedation with daily medication.

Home Remedies for Excessive Sweating (Hyperhidrosis)

  • You may be able to reduce the amount you sweat by lowering stress in your life.
  • Use a deodorant with antiperspirant. Try putting it on at night before bed.
  • Wear clothing made of material that lets your skin breathe. Cotton, wool, silk, and linen are good choices. When you exercise, wear material that removes (wicks) the moisture from your skin.

What Are the Costs of Hyperhidrosis Treatments?

The cost of hyperhidrosis therapy varies with the treatment chosen. Topical therapy and most systemic oral therapies are relatively cheap and usually covered by health care insurance. Iontophoresis machines are rather expensive but more or less free to use once obtained. The cash price for an iontophoretic unit is comparable to a single botulinum treatment course for the armpits and less than it would cost to treat both palms or both feet. Insurance will sometimes cover the cost of botulinum toxin but usually only after other measures have failed. Laser and other thermal treatments will usually be out-of-pocket costs because there is no FDA indication for them to be used in hyperhidrosis, and health care insurance companies will usually count such treatment as experimental. Cost of sympathectomy varies widely with geographic location and technique used. The costs are many times what several years of regular botulinum toxin treatments would be, but the results are permanent thereafter.

Are There Risks or Complications of Treatment?

Topical antiperspirant treatment of hyperhidrosis with aluminum chloride predictably causes some degree of irritant contact dermatitis. This may be managed by changing the frequency of application and/or the strength of the aluminum chloride from the higher prescription strengths to lower over-the-counter strengths.

Iontophoresis may be time-consuming and uncomfortable if there are cracks or fissures in the skin. This may be managed by applying petrolatum to fissures and changing the frequency of treatment. Many patients find with both iontophoresis and topical aluminum chloride that once some measure of control is obtained, they may reduce the frequency of treatments to infrequent maintenance intervals that will help reduce the irritation.

Administration of botulinum toxin is painful, especially to the palms and soles. Because the intrinsic muscles of the hands can be affected, treatment of the palms can lead to a temporary weakness of grip and dexterity of fingers until the medication wears off. Myasthenic crises is a severe myasthenia gravis-like condition that is a rare complication of botulinum toxin injection in patients who have multiple injections over several years. Myasthenic crises will wear off after several months if the injections are discontinued but may require lifesaving intervention until it does.

Systemic anticholinergic medications may cause excessive dryness of the eyes and lips. There may be difficulty urinating, and temporary inability to urinate has been reported. Dilated pupils may cause sun sensitivity to the eyes. They can cause excessive drowsiness. One of the biggest concerns for patients in hot climates is inadequate sweating. While this would seem to be a positive desired result, it may predispose the patient to heat exhaustion or heat stroke, especially if they exercise intensely while on the medication.

Sympathectomy has surgical risks inherent to the method chosen. The main concern, however, is the development of compensatory hyperhidrosis. In this setting, the target location, usually the palms, become dry after the procedure but the rest of the body has unpredictable increased sweating with stress triggers or following an activity such as eating (gustatory hyperhidrosis). In severe compensatory hyperhidrosis, the clothing may become completely soaked through shortly after starting a meal. Compensatory hyperhidrosis is common after surgical sympathectomy. This appears to be true regardless of the level of block and the method chosen. Sometimes compensatory hyperhidrosis is less responsive to systemic medications than the native hyperhidrosis.

Other surgical techniques for hyperhidrosis such as liposuction risk infection and nerve damage at the surgical site. Lasers and other thermal devices cause pain in the short-term, but may also cause actual burns and scars.

What Causes You to Sweat? Hidrosis and Hyperhidrosis

Are There Any Home Remedies for Hyperhidrosis?

A variety of home remedies may be found online, in patient support forums, and in home health books. Many of them employ herbal products that have active ingredients that work similarly to some of the prescription products described above. Others are based on inaccurate assumptions about the cause and physiology of hyperhidrosis. Typically, the main problems with these are the waste of time and money and possibly a new skin reaction to the treatments.

Sometimes these are helpful for mild hyperhidrosis.

The tannic acid in black tea applications may "cauterize" sweat glands much as aluminum chloride does. Astringents such as witch hazel may cause temporary constriction of the duct openings. Other applications have less effectiveness in decreasing sweating, but may have some antibacterial properties or mild fragrances that may help as a deodorant. These would include tea tree extract, apple cider vinegar, baking soda, sandalwood, coconut oil, and lemon juice. Increased oral intake of tomato juice, wheatgrass, and sage tea are touted as treatments that decrease sweating but there are no scientific studies to support this claim. A potential complication of the application of botanical products repeatedly to skin is the possibility of developing a sensitivity and resultant allergic skin reaction.

What Is the Prognosis of Hyperhidrosis?

There is a tendency for primary hyperhidrosis to improve with age, but unfortunately the worst of the condition occurs during late adolescence and early adulthood and complete remission occurs late if at all. Most treatments have limitations and side effects, and complete control may not be possible even with very aggressive therapy.

The prognosis for secondary hyperhidrosis is reasonably good if a reversible or surgically removable cause is identified.

Is It Possible to Prevent Hyperhidrosis?

Whether primary or secondary hyperhidrosis, there isn't any specific way to prevent its occurrence. Triggers, such as spicy foods, which might cause anybody to sweat, can be especially troublesome in patients with hyperhidrosis. These should be avoided when possible.

Hyperhidrosis Support Groups and Counseling

The International Hyperhidrosis Society (http://www.sweathelp.org/en/)

Daily Strength Hyperhidrosis Support Group (http://www.dailystrength.org/c/
Hyperhidrosis/support-group
)

Patient Hyperhidrosis Support Group (http://patient.info/support/hyperhidrosis-support-group)

One should always keep in mind that not all the advice offered in such support group sites is applicable to every patient, and not infrequently there is misinformation about the causes, triggers, and therapy for hyperhidrosis that is offered as "fact" when it really is only theory or outright inaccuracy. One must also be cautious when a particular treatment or provider is lauded as superior to all others because commercial enterprises have been known to post false and deceptive testimonials on patient support sites.

REFERENCES:

Brown, Al, J. Gordon, and S. Hill. "Hyperhidrosis: review of recent advances and new therapeutic options for primary hyperhidrosis." Curr Opin Pediatr 26.4 Aug. 2014: 460-5.

Cai, S.W., et al. "Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis." Clinics (Sao Paulo) 70.3 Mar. 2015: 214-9.

Gibbons, J.P., et al. "Experience with botulinum toxin therapy for axillary hyperhidrosis and comparison to modelled data for endoscopic thoracic sympathectomy-A quality of life and cost effectiveness analysis." Surgeon June 10, 2015.

Kouris, A., et al. "Muscle weakness in treatment of palmar hyperhidrosis with botulinum toxin type A: Can it be prevented?" J Drugs Dermatol 13.11 Nov. 2014: 1315-6.

Leclere, F.M., et al. "Efficacy and safety of laser therapy on axillary hyperhidrosis after one year follow-up: a randomized blinded controlled trial." Lasers Surg Med 47.2 Feb. 2015: 173-9.

Nicholas, R., A. Quddus, and D.M. Baker. "Treatment of Primary Craniofacial Hyperhidrosis: A Systematic Review." Am J Clin Dermatol 16.5 Oct. 2015: 361-70.

Pariser, D.M., and A. Ballard. "Iontophoresis for palmar and plantar hyperhidrosis." Dermatol Clin 32.4 Oct. 2014: 491-4.

Pieretti, L.J. "Resources for hyperhidrosis sufferers, patients, and health care providers." Dermatol Clin 32.4 Oct. 2014: 555-64.

Rezende, R.M., and F.B. Luz. "Surgical treatment of axillary hyperhidrosis by suction-curettage of sweat glands." An Bras Dermatol 89.6 Nov.-Dec. 2014: 940-54.

Semkova, K., et al. "Hyperhidrosis, bormhidrosis, and chromhidrosis: Fold (intertriginous) dermatoses." Clin Dermatol 33.4 July-Aug. 2015: 483-91.

Singh, S., H. Davis, and P. Wilson. "Axillary hyperhidrosis: A review of the extent of the problem and treatment modalities." Surgeon 13.5 Oct. 2015: 279-85.

Wolosker, N., et al. "Long-term results of the use of oxybutynin for the treatment of plantar hyperhidrosis." Int J Dermatol 54.5 May 2015: 605-11.

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