• Excessive perspiration occurring in either specific focal locations or in generalized pattern over the body
• 705.2 focal hyperhidrosis
— 705.21 primary focal hyperhidrosis
— 705.22 secondary focal hyperhidrosis
• 780.8 generalized hyperhidrosis
• 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)
• 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
• 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
• 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
• 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
• Usually chronic, with occasional spontaneous remission
• Effective treatment can improve quality of life.
• 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.
• Identify and avoid specific triggers (heat, spicy food, intense concentration, strong emotions).
For complete references, see www.dynamicmedical.com.