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hyperhidrosis

Excessive exocrine sweating (perspiration). Classification: 1) localized hyperhidrosis a) palmar/plantar hyperhidrosis b) axillary hyperhidrosis - more dependent upon temperature than palmar/plantar hyperhidrosis - may occur concurrently with palmar/plantar hyperhidrosis c) compensatory hyperhidrosis around leg ulcers 2) isolated patches on glabrous skin 2) generalized hyperhidrosis Etiology: 1) localized sweating of palms & or soles or axillae 1) idiopathic 2) anxiety 3) neurologic 2) generalized hyperhidrosis a) fever of any etiology b) neurologic disorders - spinal cord injuries - peripheral neuropathies - CNS lesions c) endocrine disorders - hyperthyroidism - diabetes mellitus - pheochromocytoma d) hypoglycemia* e) serotonin syndrome f) hypotension g) menopause h) anxiety i) alcohol j) night sweats (nocturnal diaphoresis) 3) pharmacologic agents a) antidepressants - venlaxafine, bupropion, SSRI, tricyclic antidepressants, duloxetine, opiates, clozapine, cholinergic agonists, nitrates, nitroprusside, nicotine, propafenone, fludarabine, beta-blockers (propranolol) [8] b) drug withdrawal - clonidine 4) allergic drug reactions * beta-blockers do NOT block perspiration response to hypoglycemia Epidemiology: - prevalence ~2.8% in U.S. - threshold of what prompts patient to complain of hyperhidrosis varies with individual Pathology: - eccrine glands most often associated with hyperhidrosis - highly concentrated in the face, axillae, palms, & soles [8] Clinical manifestations: 1) thin, odorless sweat* [8] 2) axillary hyperhidrosis is independent of axillary odor 3) social & emotional embarrassment 4) staining of clothing 5) reduction of self esteem 6) occupational disability - inability to handle intruments, tools or paper (palmar hyperhidrosis) * contrast with viscous odiferous sweat of axillae & groin Laboratory: - no objective clinical testing is indicated, unless systemic cause is suspected Complications: - high risk of secondary skin infection - pitted keratolysis Management: -> localized sweating of palms & or soles or axillae 1) aluminum-containing antiperspirants 2) anticholinergic-containing towelettes [6] - glycopyrronium (Qbrexza) FDA-approved June 2018 3) systemic anticholinergic agent a) propantheline: start 15 mg PO TID b) oxybutynin [5] c) doses sufficient to suppress hyperhidrosis often associated with unacceptable side effects 4) iontophoresis 5) surgery a) excision of axillary skin b) adnexectomy - indications: - age >= 21 years - at least one episode per week - bilateral & relatively symmetric locations - cessation of focal sweating during sleep - impairment of activities of daily living - positive family history c) thoracic sympathectomy is a last resort 6) botulinum toxin injection for axillary hyperhidrosis - 50 U single dose in each axilla - 50% sweat reduction [8]

Related

anhidrosis (adiaphoresis)

Specific

diaphoresis night sweats

General

perspiration (sweating)

References

  1. Stedman's Medical Dictionary 26th ed, Williams & Wilkins, Baltimore, 1995
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 928-929
  3. Medical Knowledge Self Assessment Program (MKSAP) 16 American College of Physicians, Philadelphia 2012
  4. Walling HW. Primary hyperhidrosis increases the risk of cutaneous infection: a case-control study of 387 patients. J Am Acad Dermatol. 2009 Aug;61(2):242-6 PMID: 19395123
  5. Schollhammer M, Brenaut E, Menard-Andivot N et al. Oxybutynin as a treatment for generalized hyperhidrosis: A randomized, placebo-controlled trial. Br J Dermatol 2015 Nov; 173:1163. PMID: 26114588 http://onlinelibrary.wiley.com/doi/10.1111/bjd.13973/abstract
  6. Bankhead C Topical Therapy Improves Hyperhidrosis in Kids. Sweat production falls, QOL rises with anticholineregic wipes. MedPage Today. February 20, 2018 https://www.medpagetoday.com/meetingcoverage/aad/71266 - Hebert AA, et al Glypyrronium tosylate for the treatment of primary axillary hyperhidrosis: Pediatric subgroups analyses from the ATMOS-1 and ATMOS-2 phase III randomized controlled trials. American Academy of Dermatology (AAD) 2018; Late-Breaking Research Abstract 6659.
  7. Brooks M FDA OKs New Topical Treatment for Excessive Underarm Sweating. Medscape - Jun 29, 2018 https://www.medscape.com/viewarticle/898719
  8. James W Fast Five Quiz: Hyperhidrosis Medscape. July 5, 2023 https://reference.medscape.com/viewarticle/992459 - Obed D, Salim M, Bingoel AS, Hofmann TR, Vogt PM, Krezdorn N. Botulinum Toxin Versus Placebo: A Meta-Analysis of Treatment and Quality-of-life Outcomes for Hyperhidrosis. Aesthetic Plast Surg. 2021 Aug;45(4):1783-1791. PMID: 33619611 PMCID: PMC8316174 Free PMC article.