Hyperhidrosis,Excessive sweating

Overview
Hyperhidrosis is a condition characterized by excessive sweating beyond what is required for normal thermoregulation. It may be localized (primary hyperhidrosis) or generalized (secondary hyperhidrosis). Primary hyperhidrosis typically affects the palms, soles, underarms, and sometimes the face, whereas secondary hyperhidrosis is usually caused by underlying medical conditions or medications. Excessive sweating can significantly impact daily activities, social interactions, and quality of life.

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Causes

1. Primary hyperhidrosis

   • Idiopathic, linked to overactivity of sympathetic nerves supplying sweat glands

   • Often begins in childhood or adolescence

   • Frequently localized to axillae, palms, soles, or face

2. Secondary hyperhidrosis

   • Medical conditions: diabetes mellitus, hyperthyroidism, infections (e.g., tuberculosis, HIV), malignancies (e.g., lymphoma), menopause

   • Medications: antidepressants (SSRIs, tricyclics), opioids, hypoglycemics

   • Neurological disorders: Parkinson’s disease, spinal cord injury

   • Endocrine causes: pheochromocytoma, carcinoid syndrome

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Symptoms

• Visible sweating despite absence of triggers such as heat or exercise

• Localized dampness (palms, soles, underarms, face)

• Clothing stains, odor issues, and skin maceration

• Psychological impact: embarrassment, anxiety, social withdrawal

• Night sweats in secondary hyperhidrosis

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Complications

• Skin infections (fungal, bacterial) due to persistent moisture

• Contact dermatitis

• Functional impairment (difficulty writing, handling objects, or using electronic devices)

• Emotional distress and reduced quality of life

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Diagnosis

• History and examination: determine distribution (localized vs. generalized), onset, and triggers

• Tests:

  • Starch-iodine test (for mapping sweat areas)

  • Gravimetric or evaporimetric sweat measurement

  • Laboratory investigations to rule out secondary causes: thyroid function tests, blood glucose, CBC, infection markers, and imaging if indicated

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Treatment
Treatment depends on severity and whether hyperhidrosis is primary or secondary.

1. General measures

   • Avoid triggers (spicy foods, caffeine, alcohol, heat)

   • Use breathable clothing and absorbent socks

   • Antiperspirants with high aluminum chloride concentration (topical)

2. Topical therapy

   • Aluminum chloride hexahydrate (20% solution, applied nightly then reduced to maintenance)

3. Oral medications

   • Anticholinergics (e.g., oxybutynin 2.5–5 mg orally 2–3 times daily; glycopyrrolate 1–2 mg orally twice daily)

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

   • Beta-blockers (e.g., propranolol) and benzodiazepines for situational sweating linked to anxiety

4. Procedural treatments

   • Botulinum toxin injections (Botox, Dysport): effective for axillary, palmar, and plantar hyperhidrosis; lasts 4–6 months

   • Iontophoresis: electrical current applied to water baths for hands/feet; performed several times weekly initially, then maintenance

   • Microwave thermolysis (miraDry®): destroys axillary sweat glands

5. Surgical options (severe refractory cases)

   • Endoscopic thoracic sympathectomy (ETS): cutting/clipping sympathetic nerves supplying sweat glands; effective but risk of compensatory hyperhidrosis elsewhere

   • Axillary sweat gland excision/curettage

6. Treatment of secondary hyperhidrosis

   • Manage underlying condition (e.g., antithyroid drugs for hyperthyroidism, insulin for diabetes, hormone replacement for menopause)

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Precautions

• Monitor for side effects of systemic anticholinergics

• Avoid overuse of topical aluminum chloride, as it may cause skin irritation

• Post-procedure risks (e.g., pain after Botox, compensatory sweating after ETS) should be discussed with patients

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Drug Interactions

• Anticholinergics may interact with antihistamines, tricyclic antidepressants, and antipsychotics, increasing anticholinergic side effects

• Beta-blockers may interact with hypoglycemic agents (masking hypoglycemia symptoms) and calcium channel blockers (risk of bradycardia, hypotension)

• Benzodiazepines interact with CNS depressants (opioids, alcohol, antihistamines) leading to sedation or respiratory depression

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Medications (generic names and doses)

• Aluminum chloride hexahydrate 20% topical solution: Apply nightly to affected area, then reduce frequency once controlled

• Oxybutynin: 2.5–5 mg orally 2–3 times daily

• Glycopyrrolate: 1–2 mg orally twice daily

• Propranolol: 10–40 mg orally before anxiety-inducing events

• Clonazepam (benzodiazepine): 0.25–0.5 mg orally at bedtime (short-term use only)

• Botulinum toxin type A: 50–100 units injected per axilla (divided into multiple sites