- Signs & Symptoms
Excessive sweating (hyperhidrosis) facts
- Hyperhidrosis, or excessive sweating, is a common disorder.
- It can be localized to a particular anatomical area or maybe diffuse, involving much of the skin.
- Axillary hyperhidrosis is excess sweating of the underarms.
- Palmoplantar hyperhidrosis is excess sweating of the palms and soles.
- Hyperhidrosis usually occurs in people who are otherwise healthy.
- This condition is treatable, and those affected can expect significant improvement.
What is excessive sweating (hyperhidrosis)?
The word hidrosis is derived from the Greek and simply means "sweat." Hyperhidrosis, excessive sweat or excessive sweating, produces a lot of embarrassment and unhappiness.
- Primary hyperhidrosis occurs in otherwise healthy individuals with no apparent cause.
- Secondary hyperhidrosis is much less common and can be due to certain drugs, a variety of serious systemic diseases, neurological disorders, facial surgery, and anxiety.
Of the approximately 3% of Americans who suffer from excessive sweating, 50% involve underarms (axillary hyperhidrosis). Underarm problems tend to start around puberty, while palm and sole sweating may begin earlier, often during childhood. Untreated, these problems may continue throughout life.
Sweating is embarrassing, stains clothes, and may complicate business and social interactions. Excessive sweat can have serious practical consequences, like making it difficult to hold tools, grip a steering wheel, or shake hands.
What causes hyperhidrosis excessive sweating?
Otherwise healthy people with excessive sweating have primary hyperhidrosis. Heat and emotions may trigger hyperhidrosis in some, but many who suffer from hyperhidrosis perspire nearly all the time, regardless of their mood or the weather.
Secondary hyperhidrosis can be caused by medications such as dopamine agonists, antidepressants, antipsychotics, alcohol, and insulin. Systemic disorders such as diabetes mellitus, hyperthyroidism, Parkinson's disease, and tumors such as pheochromocytoma and lymphoma have been associated with secondary hyperhidrosis.
What signs and symptoms accompany hyperhidrosis?
Generally, the only sign of excessive sweating is the presence of abundant moisture in the anatomical area affected. The presence of this moisture can predispose to skin infections.
What are the risk factors for hyperhidrosis?
As stated above, several conditions and diseases produce secondary hyperhidrosis. Treating the underlying condition can help relieve at least some of the excessive sweating.
How do healthcare professionals diagnose hyperhidrosis?
The diagnosis is made clinically based on a patient's history and physical examination. If the sweating is excessive and constant, then the diagnosis is obvious. It is not unusual that one must rely on the patient's history to determine the diagnosis. Research centers measure sweat production by comparing the weight of filter paper left on the skin for a specified interval before and after sweating.
Dermatologists are physicians specialized in diagnosing and treating skin conditions. Dermatologists diagnose and treat this condition.
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What are medical treatment options for hyperhidrosis?
Through a systematic evaluation of causes and triggers of excessive sweating, followed by a judicious, stepwise approach to medical treatment, many people with this annoying disorder can achieve an improved quality of life. The decision on initial treatment depends upon the severity of the condition and the anatomical areas that are affected.
The approach to treating hyperhidrosis generally proceeds as follows:
- Over-the-counter antiperspirants: Patients usually try home remedies like these first because they are readily available. Antiperspirants containing aluminum chloride (for example, Certain-Dri) may be more effective when other antiperspirants have failed. So-called "natural" antiperspirants are often not very helpful for patients.
- Prescription-strength antiperspirants: those containing aluminum chloride hexahydrate
- Iontophoresis: a device that uses a direct current to drive ions into the sweat gland using tap water occasionally mixed with aluminum ions or other substances
- Oral medications: from the group of medications known as anticholinergics, which reduce sweating
- Topical medicated pads: pads impregnated with anticholinergic medications for use in the armpits
- Botox (botulinum toxin): approved in the U.S. by the Food and Drug Administration (FDA) for treating excessive axillary sweating
- Microwave destruction: a device destroys the sweat glands, purportedly causing minimal damage to other tissues
- Surgery: paraspinal sympathectomy, or interruption of certain nerve pathways, as a last resort
Aluminum chloride hexahydrate
When regular antiperspirants fail, as they often do, to remedy hyperhidrosis, most doctors start by recommending aluminum chloride hexahydrate (Drysol, various generics), a prescription-strength version of aluminum chloride. It is applied just before bedtime seven to 10 nights in a row, then roughly once a week as a maintenance medication. The aluminum salts in this preparation collect in the sweat ducts of the patient and block them. Over time, the excessive perspiration may diminish to such an extent that no further treatment is needed. This method works reasonably well for many patients whose problem is excessive underarm sweating, but it's not satisfactory for most of those with clammy palms and sweating of the soles of the feet.
The main side effect of aluminum chloride is irritation, which can sometimes, but not always, be overcome by reducing the frequency of use or applying anti-inflammatory medications such as lotions containing hydrocortisone.
Iontophoresis was introduced over 50 years ago to treat excessive sweating. Its exact mechanism of action is still unclear. The procedure uses water to conduct an electric current to the skin, which combats the production of sweat. The current is applied typically for 10-20 minutes per session, initially with two to three sessions per week followed by a maintenance program of treatments at one- to three-week intervals, depending upon the patient's response. Iontophoresis treatments sound painful but are not.
Patients purchase devices for this treatment through a doctor's prescription. Three iontophoresis devices are registered with and cleared by the U.S. FDA; the R.A. Fischer and the Hidrex USA devices require a prescription, whereas the Drionic device is available without a prescription. They work best on palms and soles but can be adapted for use in the underarms. Medical insurers sometimes cover the cost.
Oral anticholinergic drugs such as glycopyrrolate (Robinul), oxybutynin, and propantheline bromide can be quite effective for this condition, but they can produce side effects like dry mouth, insomnia, and blurred vision. The dosage should be titrated carefully.
Topical anticholinergic pads
Recently, a new topical treatment using glycopyrronium tosylate-impregnated gauze pads (Qbrexza) has received approval for the treatment of axillary (armpit) hyperhidrosis.
Botulinum toxin (Botox), a muscle poison much in the news as a cosmetic treatment for wrinkles, has been used in many areas of medicine for some time, such as in the treatment of muscle spasms and certain types of headaches. Its latest medical use is for treating excessive underarm sweating.
Botox is injected into tissues of the armpit or hand. The drug works by inhibiting the release of acetylcholine, which is the chemical that activates sweat glands. This may produce approximately six months of relief from sweating. The injections are uncomfortable, but the use of a very small needle minimizes discomfort.
Now that this treatment option has received FDA approval, many health insurers are providing coverage for the injections and Botox itself, which is quite costly.
Currently, the FDA has not approved Botox for treating sweating of the palms and soles of the feet, though some physicians are administering it as an off-label use, with some success. Drawbacks of using this treatment for the palms and soles are pain, requiring nerve blocks to numb the hands to make the injections tolerable, and the potential for temporary muscle weakness.
Microwave, laser, and ultrasound destruction
These new techniques produce energy that presumably destroys sweat glands while preserving other tissues. Currently, only the armpits seem to be appropriate treatment sites. Treatments occur in a doctor's office and in recent studies have been accompanied by local swelling and irritation as well as a variety of other relatively minor side effects. Sweating seems to be significantly decreased for a time with these treatments. How these would be used in other anatomical areas aside from the armpits is not clear.
Can surgery treat hyperhidrosis?
Localized axillary hyperhidrosis has been treated by surgical removal of a substantial portion of axillary skin. Another approach is the use of liposuction curettage, although how this effectively damages the dermal sweat glands is hard to visualize.
Endoscopic thoracic sympathectomy (ETS) refers to the surgical interruption of the sympathetic nerves responsible for sweating. Sympathectomy is an operation intended to destroy part of the nerve supply to the sweat glands in the skin. The surgeon inserts a special endoscopic instrument into the chest between two ribs just below the armpit. The lung is briefly deflated to better visualize and destroy the nerves. Sympathectomy is both effective and risky.
Even with newer endoscopic techniques, complications of the procedure can include compensatory, excessive sweating in other parts of the body as well as lung and nerve problems. As many of these complications are serious and not reversible, this option is rarely used, and then only as a last resort.
What is the prognosis for hyperhidrosis?
Most hyperhidrosis patients can be effectively and safely treated.
Where can people find more information about hyperhidrosis?
An excellent source of information is the International Hyperhidrosis Society (https://www.sweathelp.org/).
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Hashmonai, Moshe, et al. "The Etiology of Primary Hyperhidrosis: A Systematic Review." Clin Auton Res 2017. DOI 10.1007/s10286-017-0456-0.
Hosp, Christine, and Henning Hamm. "Safety of Available and Emerging Drug Therapies for Hyperhidrosis." Expert Opinion on Drug Safety 2017. DOI: 10.1080/14740338.2017.1354983.
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