Hyperhidrosis Center

16-year-old girl with sweating - Grand Rounds
Clinician Reviews, April, 2002 by Cindy Grandjean.

A 16-year-old girl presents complaining of excessive axillary and palmar sweating. The sweating increases with stress and does not seem to be associated with room temperature or other factors. The patient denies any family history of excessive sweating and reports that she does not take prescription or over-the-counter medications on a regular basis.

Examination of this patient is normal except for frank perspiration noted on her palms and in the axillary region bilaterally. Routine blood screening, including a thyroid profile, complete blood cell count, and complete metabolic panel, reveals normal results.

DISCUSSION

This patient has a medical condition called primary hyperhidrosis. Approximately 0.6% to 1.0% of young people have this condition characterized by excessive sweating in various locations on the body--most commonly the palms, soles, head, face, or axillae. (1) Incidence appears to be equal between the sexes. Though benign, hyperhidrosis presents the patient with significant psychological and social concerns (see "Hyperhidrosis Is No Small Problem," page 97).

Hyperhidrosis can be classified as either primary or secondary (see Table 1, (2,3) page 94). Primary (or essential) hyperhidrosis is the most common cause of palmoplantar sweating and often starts during adolescence--although, as is true in the case presented here, it can begin in childhood or even infancy Furthermore, a careful family history may provide a clue to this diagnosis, since primary hyperhidrosis often may be an inherited disorder. (2) Sweating is usually localized, and while heat and emotional stimuli can precipitate sweating, patients with essential hyperhidrosis may exhibit symptoms even without these stimuli. (3)

Secondary hyperhidrosis must be carefully ruled out prior to arriving at a diagnosis of primary hyperhidrosis because it is commonly associated with an underlying medical problem (see Table 2, page 94) or use of certain medications (eg, propranolol, pilocarpine, tricyclic antidepressants, selective serotonin reuptake inhibitors, and venlafaxine). While secondary hyperhidrosis may present as localized (eg, palmoplantar), it is often characterized by a more generalized pattern of sweating that occurs during both daytime and nighttime hours. (2)

DIAGNOSIS

Primary hyperhidrosis can be diagnosed based on the patient's medical and family history, symptom presentation, and a physical examination with normal findings. Although there are no diagnostic tests to confirm primary hyperhidrosis, metabolic and infectious disorders that may be responsible for secondary hyperhidrosis can be ruled out by performing laboratory tests such as a complete blood cell count, a thyroid-stimulating hormone level, follicle-stimulating hormone and luteinizing hormone levels, chemistry panel, fasting blood sugar, prolactin panels, and plasma-free testosterone. (4)

TREATMENT

If an underlying cause for the sweating can be identified, it should be treated. If, on the other hand, no underlying cause is identified, there are several options for treating primary hyperhidrosis, including topical solutions, oral medication, iontophoresis, botulinum toxin injections, liposuction, and surgery.

Topical solutions. Preparations containing aluminum chloride and tanning agents have been used to treat patients with mild to moderate symptoms. Although the exact mechanism by which these products decrease hyperhidrosis is unknown, some experts suggest that aluminum chloride mechanically obstructs the sweat pores, resulting in atrophy of the secretory cells. (5) Over-the-counter products containing aluminum chloride have been found to be particularly successful in the treatment of axillary hyperhidrosis; however, products that contain higher percentages of aluminum chloride may be required to treat moderate to severe cases. Solutions containing 25% tannic acid or glutaraldehyde and formaldehyde solutions (5% to 20%) are used to treat plantar hyperhidrosis. Topical solutions have limited usefulness in cases of severe hyperhidrosis.

When appropriate, these products should be applied to intact, dry skin. Advise patients to spread the agents on the skin two or three times a week at bedtime and then rinse the solution off in the morning. It is also important to inform patients that these solutions may irritate and stain the skin, and may also stain clothes and bed linens.

Oral treatments. A few systemic medications have been used to treat hyperhidrosis, including diazepam, anticholinergics, nonsteroidal anti-inflammatory drugs (eg, indomethacin), and calcium channel blockers (diltiazem and clonidine hydrochloride). (2) Not only do these drugs all have potentially significant adverse effects, they have not been particularly successful in reducing sweating.

Iontophoresis. This therapy involves applying a mild electrical current to the area of skin that produces excessive sweat. Patients often need to be treated with this electrical current every other day for four to six sessions. Electrical stimulation has been found to be effective in reducing symptoms of palmar and foot hyperhidrosis and less so in the treatment of axillary hyperhidrosis. (6)

Botulinum toxin injections. Intracutaneous injections of botulinum toxin (BTX) have been found to decrease sweating by blocking the release of acetylcholine in the neuromuscular junction and by inhibiting cholinergic transmission in postganglionic sympathetic cholinergic fibers to sweat glands. (7) Before administering this therapy (as well as surgical options), the specialist must identify the area of excessive sweating by using the colorimetric Minor's starch-iodine test. (8,9)

Adverse effects associated with BTX are bruising, discomfort, and muscle weakness at the injection sites. BTX injections in the palms have been associated with some hand weakness, but this is usually mild and transient. Although these injections are not curative, most patients experience anhidrosis for a period of three to eight months. (10) The cost of BTX therapy is approximately $700 to $1,000 per course of treatment.

Liposuction. Liposuction has been used to treat axillary hyperhidrosis that is refractory to more conservative treatments. During this procedure, two or three incisions are made in the axillae so that a cannula may be inserted and manipulated in a windshield wiper-like fashion to scrape the undersurface of the dermis and aspirate the sweat glands. (9,11)

Surgery. Since the 1980s, thoracoscopic surgery has gradually replaced an older, dorsal-sympathetic approach. During surgery, a thoracoscope is inserted into the pleural cavity and specific ganglia are resected, depending on where the patient experiences the sweating. Reports indicate that this procedure is effective 94% to 98% of the time with approximately 1% rate of recurrence. However, this surgical intervention has been associated with serious adverse effects, including compensatory sweating, pneumothorax, segmental collapse of the lung, and wound infections. (12,13)

CONCLUSION

Primary care providers should not dismiss complaints of axillary and palmar sweating, as this condition can impede a patient's social life and impact productivity. A diagnosis of essential hyperhidrosis may be established after the clinician has taken a careful history, conducted a thorough physical examination, and ordered the appropriate laboratory studies to rule out hyperhidrosis that is secondary to another condition. Depending on disease severity, the primary care provider may attempt a trial of topical or oral agents. If the sweating persists, the practitioner should consider referring the patient to a dermatologist for further evaluation.

Table 1 CHARACTERISTICS OF PRIMARY AND SECONDARY HYPERHIDROSIS (2,3) Primary Onset Adolescence Family May be present in history other family members Presentation Sweating is localized to hands, feet, scalp, and axillae; only occurs during the day; worsens with heat and stress Secondary Onset Usually new symptom, any age Family None history Presentation Generalized pattern of sweating; occurs during daytime and nighttime hours TABLE 2 MEDICAL CONDITIONS THAT CAN CAUSE SECONDARY HYPERHIDROSIS (2,3) Generalized sweating Localized sweating Febrile illness Raynaud's disease Neoplastic and neurologic diseases Rheumatoid arthritis Metabolic disorders Erythromelalgia Diabetes mellitus Nail-patella syndrome Thyrotoxicosis Keratosis palmaris et plantaris Pheochromocytoma Atrioventricular fistula Hyperpituitarism Cold injury Menopause Riley-Day syndrome

REFERENCES

(1.) Lee DY, Yoon YH, Shin HK, et al. Needle thoracic sympathectomy for essential hyperhidrosis: intermediate-term follow-up. Ann Thorac Surg. 2000;69:251-253.

(2.) Stolman LP. Treatment of hyperhidrosis. Dermatol Clin. 1998;16:863-869.

(3.) Moyer P. Derms best equipped to diagnose, treat hyperhidrosis. Dermatol Times. 1997;18:31-32.

(4.) Kim SS, Rosenfield RL. Hyperhidrosis as the only manifestation of hyperandrogenism in an adolescent girl. Arch Dermatol. 2000;136:430-431.

(5.) Torch EM. Remission of facial and scalp hyperhidrosis with clonidine hydrochloride and topical aluminum chloride. South Med J. 2000;93:68-69.

(6.) Munson M. Sweat solutions. Prevention. 1993;45(9):53c.

(7.) Heckmann M, Ceballos-Baumann AO, Plewig G, for the Hyperhidrosis Study Group. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. 2001;344:488-493.

(8.) Guttman C. Botulinum: a new wrinkle on handling hyperhidrosis. Dermatol Times. 1999;20:1-3.

(9.) Swinehart JM. Treatment of axillary hyperhidrosis: combination of the starch-iodine test with the tumescent liposuction technique. Dermatol Surg. 2000;26:392-396.

(10.) Naumann M, Flachenecker P, Brocker EB, et al. Botulinum toxin for palmar hyperhidrosis. Lancet. 1997;349:252.

(11.) Guttman C. Botulinum toxin, liposuction new options for treating axillary hyperhidrosis. Dermatol limes. 1999;20(2):20-21.

(12.) Lin TS, Fang HY. Transthoracic endoscopic sympathectomy in the treatment of palmar hyperhidrosis--with emphasis on perioperative management (1,360 case analyses). Surg Neurol. 1999;52:453-457.

(13.) Hsu CP, Chen CY, Hsia JY, Shai SE. Resympathectomy for palmar and axillary hyperhidrosis. Brit J Surg. 1998;85:1504-1505.

RELATED ARTICLE: HYPERHIDROSIS IS NO SMALL PROBLEM

Hyperhidrosis is not a life-threatening disease, yet managing its symptoms can improve quality of life for affected patients. For example, the girl featured in the case study had experienced excessive sweating throughout childhood. However, the problem began to have a significant impact on her social life as she became a teenager. The patient reported needing to change her clothes several times a day because of large perspiration stains; she avoided shaking hands or touching her friends because her palms were always moist. She also stopped participating in the school band because the excessive moisture on her hands damaged the strings of her violin. The patient had used many different brands of antiperspirant to help remedy this problem with no success.

If she had not sought help for her excessive sweating, she may have found, as others with this condition have found, that having hyperhidrosis can even influence one's choice of employment. Careers that involve significant contact with paperwork, metal, or electrical equipment may be impractical for persons who sweat profusely.

Cindy Grandjean is an Assistant Professor at the Uniformed Services University of Health Services and is an Adult and Geriatric Nurse Practitioner at Calvert Internal Medicine in Dunkirk, Maryland.

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