Hyperhidrosis

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Description

• Excessive perspiration occurring in either specific focal locations or in generalized pattern over the body

ICD-9 codes

• 705.2 focal hyperhidrosis 
    — 705.21 primary focal hyperhidrosis 
    — 705.22 secondary focal hyperhidrosis
• 780.8 generalized hyperhidrosis

Types

• Focal hyperhidrosis (also called “primary,”  “idiopathic,” or “essential” hyperhidrosis)
    — Palmar-plantar hyperhidrosis: excess sweating of palms of hands and soles of feet 
    — Isolated axillary hyperhidrosis: excess sweating of underarms 
    — Craniofacial hyperhidrosis: isolated excess sweating of face 
    — Gustatory hyperhidrosis: excess sweating of face triggered by spicy foods
• Generalized hyperhidrosis (also called “secondary” hyperhidrosis)

Organs involved

• Skin, autonomic nervous system

Who is most affected

• Males and females equally affected
• 2.9% prevalence of hyperhidrosis in U.S. survey; 1.4% have axillary hyperhidrosis

Causes

• Focal — likely due to overactivity of sudomotor system, often associated with response to emotional stimuli
• Compensatory hyperhidrosis in one area due to absence of sweating on another part of
body post injury (e.g., damage to sympathetic trunk, diabetic neuropathy, post-thoracic sympathectomy)
• Generalized hyperhidrosis (secondary) due to:
    — Neurologic diseases, including autonomic dysreflexia, orthostatic hypotension, spinal- cord injury, syringomyelia, certain types of epilepsy, and some hypothalamic lesions
    — Malignancies, including leukemia, Hodgkin's disease, and renal adenocarcinoma among others
    — Endocrine conditions, including acromegaly, diabetes mellitus, pheochromocytoma, and hyperthyroidism 
    — Chronic infections, such as tuberculosis and brucellosis
    — Cardiovascular conditions, including congestive heart failure and myocardial ischemia
    — Respiratory failure 
    — Certain medications, including antidepressants (venlafaxine [Effexor XR] and bupropion [Wellbutrin XL or SR]), opiates (methadone, oxycodone, etc.), insulin, analgesics (aspirin and acetaminophen), antihypertensives (nitrates and nitroprusside), and nicotine

Pathogenesis

• Response to sensation or emotion stimulates activity in anterior cingulate frontal cortex.
• Mental stress may stimulate sympathetic nervous system resulting in cutaneous vasoconstriction and excess sweating.
• No association with histopathologic changes in sweat glands or numbers of sweat glands

Risk factors

• Family history 
    — May be inherited as autosomal dominant or recessive trait
    — Primary palmar hyperhidrosis appears hereditary, with variable penetrance.
• Mental or emotional stress

Complications and associated conditions

• Skin complications
    — Maceration increases risk of bacterial/ fungal infection  
    — Bromhidrosis (foul-smelling sweat) 
    — “Pompholyx” is type of eczema causing blisters on palms and/or soles. 
    — Chromhidrosis (darkened facial skin) 
    — Predisposition to contact dermatitis
• Potential for social embarrassment

History and screening

• Age of onset at puberty
• Typically affects axillae, palms, soles, or craniofacial region
• Often associated with social anxiety or embarrassment
• Patient may feel need to change clothing frequently.
• Screen closely for nervous or endocrine system disorders. 

Diagnosis and testing

• Look for evidence of excess sweating, maceration, or pigmentation in characteristic regions (axillae, palms, soles, or craniofacial region).
• History of visible, excessive (episodic) sweating for at least six months, occurring in characteristic focal regions without detectable underlying cause, and at least two of following: 
    — Occurs symmetrically on both sides of body 
    — Impairs activities of daily living
    — Occurs more than once per week
    — Age of onset <25 years old
    — Positive family history (up to 50% of cases)
    — Symptoms do not occur during sleep.
• Generalized hyperhidrosis more likely associated with underlying systemic condition
• Lab testing usually not needed if characteristic presentation
• Minor's starch-iodine test (delineates affected area )
• Gravimetric analysis or dynamic sudorometry (determines rate of sweat production)
• Thermoregulatory sweat test

Prognosis

• Usually chronic, with occasional spontaneous remission  
• Effective treatment can improve quality of life.

Treatment

• Sweat reduction/concealment (loose clothing/antiperspirant/talc powder)
• Axillary or palmar hyperhidrosis
    — 20% aluminum chloride hexahydrate (antiperspirant)
    — Topical or intradermal botulinum toxin type A (B for palmar)
    — Endoscopic thoracic sympathetic block
    — Sympathectomy at T3-T4 level 
    — Tap water iontophoresis (for palmar)
• Glycopyrrolate 0.5% topical cream, botulinum toxin type A, or clonidine for facial or gustatory hyperhidrosis

Consultation and referral 

• Dermatology as needed
• Consider consultation with mental health provider for severe social anxiety.

Prevention

• Identify and avoid specific triggers (heat, spicy food, intense concentration, strong emotions).

For complete references, see www.dynamicmedical.com

Dr. Brier is an editor for DynaMed, a database of comprehensive updated summaries covering more than 3,000 clinical topics. Ms. Wynne is associate director of education for the American Academy of Nurse Practitioners and a reviewer for DynaMed.

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