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Hyperhidrosis is a condition in which one sweats more than is required by the body for thermoregulation. Localized hyperhidrosis typically begins in the first or second decade of life, most often affecting the palms, soles, and axillae (under arms), whereas generalized hyperhidrosis usually occurs later in life.. Excessive sweating can be essential (there is no other underlying disorder), or, when generalized, can be secondary to metabolic disorders, infection, neurological disorders, cancer, alcoholism, or medication usage. Hyperhidrosis is often categorized as either emotionally induced (affecting palms, soles, and axillae), localized, or generalized. Localized hyperhidrosis has also been described in connection with a number of other conditions. Hyperhidrosis is not uncommon, with an incidence of about 1% reported in young adults. It can result in embarrassment and social restriction, and limit activities and employment.
With what can hyperhidrosis be confused?
It would be rare to confuse hyperhidrosis with any other condition, but the cause must be elucidated, and hyperhidrosis secondary to other conditions ruled out if the condition is generalized.
How is hyperhidrosis diagnosed?
Hyperhidrosis is usually easy to detect clinically, evidenced by sweat stained clothing or sweaty palms and soles. Areas with sweat can be visualized using the iodine starch test, which is useful prior to treatment.
Primary causes of hyperhidrosis need to be sought if the condition is generalized. A basic workup may include thyroid function tests, blood glucose level, and PPD placement for tuberculosis testing. Further workup might include investigations for gout, pheochromocytoma, or other neoplasms.
How is hyperhidrosis treated?
Localized essential hyperhidrosis is the most common type seen by dermatologists.
Microwave. miraDry, can reduce axillary hyperhidrosis by destroying sweat glands with microwave heat. This is reported to be highly effective after two treatments.
Topical treatment. Drysol (20% aluminum chloride hexahydrate in anhydrous ethyl alcohol) is the most common first-line agent. It is applied nightly to the affected area, sometimes under occlusion, and washed off in the morning. Once improvement is seen, treatment may be reduced to less frequent intervals. Other topical agents are sometimes used, but most have fallen out of regular use in favor of Drysol.
Systemic medications. Systemic medications may be used as well, typically an anticholinergic drug, such as glycopyrrolate. This may be limited by typical anticholinergic side effects such as dry mouth, dry eyes, urinary retention and constipation.
Iontophoresis. Iontophoresis is the passage of direct current through the skin. Its exact mechanism of action in hyperhidrosis is not clear, but it is reported to be effective. Commercial devices are available for this treatment, typically applying small amounts of current to each palm and sole for 30 minutes each day.
Botox injections for hyperhidrosis. Botox injections into the effected areas will cause a temporary denervation of the cholinergic neurons responsible for sweating. In the treatment of palmar hyperhidrosis, many small injections are made, typically of 2 units each per palm, for a total of about 100 units per palm. Treatment is effective for 4 to 12 months. It is possible to experience some transient weakness of the thumb, likely due to diffusion of Botox into the underlying muscle, typically resolving in several weeks. Axillary hyperhidrosis may be treated in a similar fashion.
Surgery. Other possibilities include surgical removal of the affected areas (typically axillary), liposuction of the affected area (destroying the glands with the liposuction cannula), or sympathectomy (severing of nerves that induce sweating in the affected area.)
Laser. Laser ablation of the affected sweat glands may be an attractive alternative. In a small study, treatment of axillary hyperhidrosis with a 1064-nm Nd-YAG laser was reported to be effective. Another study, however, reported an increase in axillary sweating following the use of a 1064-nm Nd-YAG for axillary laser hair reduction. Further study is required.
What is the prognosis for hyperhidrosis?
Hyperhidrosis is difficult to treat. For secondary hyperhidrosis, correction of the underlying condition will typically lead to resolution. Primary hyperhidrosis may be resistant to treatment and repeated treatments are necessary to maintain control. However, with the arsenal of topical, systemic, and surgical approaches, many patients can achieve good results.
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