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Saturday, August 23, 2025

Excessive sweating (hyperhidrosis)


Introduction

Sweating is a normal thermoregulatory function that maintains body temperature by evaporative cooling. However, when sweating becomes excessive, disproportionate, and socially/physically disabling, it is termed hyperhidrosis. This condition may be localized (palms, soles, axillae, face) or generalized, and may occur spontaneously or in response to stimuli like stress or heat.

Hyperhidrosis affects approximately 2–3% of the population, with onset commonly in adolescence or early adulthood. Although not life-threatening, it has profound effects on quality of life, leading to social embarrassment, occupational limitations, and psychological distress.

Classification of Hyperhidrosis

1. Primary (Idiopathic, Focal) Hyperhidrosis

  • Localized (palms, soles, axillae, face/scalp).

  • Onset usually in childhood/adolescence.

  • Symmetrical distribution.

  • Likely due to overactivity of sympathetic cholinergic fibers.

2. Secondary (Generalized) Hyperhidrosis

  • Caused by underlying systemic or iatrogenic factors.

  • Can occur during sleep (unlike primary hyperhidrosis).

  • Causes include:

    • Endocrine/metabolic: Diabetes mellitus, hyperthyroidism, pheochromocytoma, menopause (hot flashes).

    • Infections: Tuberculosis, HIV, malaria, endocarditis.

    • Neurological disorders: Parkinson’s disease, spinal cord injuries.

    • Malignancies: Lymphoma, leukemia (night sweats).

    • Drugs: Antidepressants (SSRIs, TCAs), opioids, hypoglycemics, alcohol, caffeine.

Pathophysiology

  • Sweat is produced by eccrine glands, innervated by sympathetic cholinergic fibers (unusual, as most sympathetic nerves are adrenergic).

  • In primary hyperhidrosis, there is increased sympathetic outflow, not related to thermoregulation.

  • In secondary hyperhidrosis, the mechanism depends on the underlying disease (e.g., excess catecholamines in pheochromocytoma).

Clinical Presentation

Patients may present with:

  • Visible sweating beyond physiologic needs.

  • Palmar sweating → difficulty holding objects, shaking hands.

  • Axillary sweating → soaked clothing.

  • Plantar sweating → slipping in footwear.

  • Facial sweating → visible dripping, social embarrassment.

  • Associated symptoms of systemic disease: weight loss, palpitations, fever, tremor, lymphadenopathy, night sweats.

Diagnostic Approach

1. Clinical Evaluation

  • Detailed history: Onset, duration, symmetry, triggers, family history.

  • Distinguish primary vs. secondary hyperhidrosis.

  • Night sweats suggest systemic illness.

2. Investigations

  • Basic labs: CBC, blood glucose, thyroid function tests, ESR/CRP.

  • Hormonal tests: Catecholamines/metanephrines (pheochromocytoma).

  • Infectious workup: Tuberculosis screening, HIV test if indicated.

  • Imaging: Chest X-ray/CT (lymphoma, TB).

3. Diagnostic Tests for Hyperhidrosis

  • Minor starch-iodine test: Highlights areas of sweat.

  • Gravimetric measurement: Weighing filter paper after application to skin.

  • Quality of life questionnaires (Hyperhidrosis Disease Severity Scale, HDSS).

Management and Treatment

Treatment depends on severity and cause.

A. General Measures

  • Avoid triggers (spicy food, caffeine, alcohol, heat).

  • Wear loose, breathable clothing.

  • Psychological support and counseling.

B. First-Line Medical Therapy

1. Topical Antiperspirants

  • Aluminum chloride hexahydrate 20% solution:

    • Apply to dry skin at night, wash off in morning.

    • Effective for axillary, palmar, and plantar hyperhidrosis.

    • May cause skin irritation → use hydrocortisone cream 1% if irritation occurs.

2. Topical Anticholinergics

  • Glycopyrronium cloths (2.4% solution): Apply once daily to axillae.

  • Oxybutynin 3% topical gel: Applied once daily to affected area.

C. Systemic Medications

1. Oral Anticholinergics

  • Oxybutynin: 2.5–5 mg orally two to three times daily.

  • Glycopyrrolate: 1–2 mg orally twice daily.

    • Side effects: dry mouth, constipation, blurred vision, urinary retention.

2. Beta-Blockers (for anxiety-induced sweating)

  • Propranolol: 10–40 mg orally, 30–60 minutes before stress-inducing events.

3. Benzodiazepines (situational, short-term use)

  • Clonazepam: 0.25–0.5 mg orally as needed for anxiety-related hyperhidrosis.

D. Botulinum Toxin Injections (Highly Effective)

  • OnabotulinumtoxinA (Botox):

    • Dose: 50 units per axilla (multiple intradermal injections).

    • Duration of effect: 6–9 months.

    • Useful for axillary, palmar, plantar hyperhidrosis.

E. Iontophoresis

  • Electrical current passed through tap water baths containing hands/feet.

  • Performed 2–3 times per week.

  • Effective for palmar and plantar hyperhidrosis.

F. Surgical and Advanced Options

  1. Endoscopic Thoracic Sympathectomy (ETS):

    • Permanent solution for severe palmar/axillary hyperhidrosis.

    • Interrupts sympathetic chain (T2–T4).

    • Risks: compensatory sweating elsewhere, pneumothorax, Horner’s syndrome.

  2. Excision or curettage of axillary sweat glands:

    • Useful for localized axillary sweating.

G. Secondary Hyperhidrosis: Treat Underlying Cause

  • Diabetes mellitus:

    • Metformin 500 mg orally twice daily, titrate as needed.

  • Hyperthyroidism:

    • Methimazole 10–30 mg orally daily or

    • Propylthiouracil (PTU) 100–150 mg orally three times daily.

  • Tuberculosis:

    • Isoniazid 300 mg daily + Rifampin 600 mg daily + Pyrazinamide 25 mg/kg daily + Ethambutol 15 mg/kg daily (initial 2 months).

  • Lymphoma/night sweats: Chemotherapy protocols as per oncologist.

  • Drug-induced sweating: Review and stop offending medication (SSRIs, opioids, lithium).

Complications of Hyperhidrosis

  • Dermatological: Maceration, fungal/bacterial skin infections.

  • Psychological: Anxiety, depression, social phobia.

  • Occupational: Impaired manual dexterity (palmar sweating), damage to documents/electronics.

  • Post-surgical: Compensatory sweating (ETS).

Prognosis

  • Primary hyperhidrosis: Chronic but manageable with medical and surgical therapy.

  • Secondary hyperhidrosis: Depends on underlying disease; resolves if root cause treated.

  • Quality of life: Significantly improved with effective therapy (especially botulinum toxin and iontophoresis).

Patient Education

  • Explain benign nature of primary hyperhidrosis.

  • Emphasize available treatments (not a condition to “live with”).

  • Lifestyle modifications: hydration, breathable fabrics, stress management.

  • Regular follow-up if systemic disease suspected.




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