Hyperhidrosis


Hyperhidrosis is a medical condition in which a person exhibits excessive sweating, more than is required for the regulation of body temperature. Although it is primarily a physical burden, hyperhidrosis can deteriorate the quality of life of the people who are affected, frequently leading to psychological, physical, and social consequences. Hyperhidrosis can lead to difficulties in professional fields, with more than 80% of patients experiencing moderate to severe emotional effects from the disease.
This excess of sweat happens even if the person is not engaging in tasks that require muscular effort, and it does not depend on the exposure to heat. Common places to sweat can include underarms, face, neck, back, groin, feet, and hands. It has been called by some researchers 'the silent handicap'.
Both diaphoresis and hidrosis can mean either perspiration or excessive perspiration, in which case they refer to a specific, narrowly defined, clinical disorder.

Classification

Hyperhidrosis can either be generalized, or localized to specific parts of the body. Hands, feet, armpits, groin, and the facial area are among the most active regions of perspiration due to the high number of sweat glands in these areas. When excessive sweating is localized it is referred to as primary hyperhidrosis or focal hyperhidrosis. Excessive sweating involving the whole body is termed generalized hyperhidrosis or secondary hyperhidrosis. It is usually the result of some other, underlying condition.
Primary or focal hyperhidrosis may be further divided by the area affected, for instance, palmoplantar hyperhidrosis or gustatory hyperhidrosis.
Hyperhidrosis can also be classified by onset, either congenital or acquired. Primary or focal hyperhidrosis usually starts during adolescence or even earlier and seems to be inherited as an autosomal dominant genetic trait. It must be distinguished from secondary hyperhidrosis, which can start at any point in life, but usually presents itself after 25 years of age. Secondary hyperhidrosis commonly accompanies conditions such as diabetes mellitus, Parkinson's disease, hyperthyroidism, hyperpituitarism, anxiety disorder, pheochromocytoma, and menopause.
One classification scheme uses the amount of skin affected. In this scheme, excessive sweating in an area of or more is differentiated from sweating that affects only a small area.
Another classification scheme is based on possible causes of hyperhidrosis.

Causes

The cause of primary hyperhidrosis is unknown. Anxiety or excitement can exacerbate the condition. A common complaint of people is a nervous condition associated with sweating, then sweating more because the person is nervous. Other factors can play a role, including certain foods and drinks, nicotine, caffeine, and smells.
Similarly, secondary hyperhidrosis has many causes including certain types of cancer, disturbances of the endocrine system, infections, and medications.

Primary

Primary hyperhidrosis has many causes.
A variety of cancers have been associated with the development of secondary hyperhidrosis including lymphoma, pheochromocytoma, carcinoid tumors, and tumors within the thoracic cavity.

Endocrine

Certain endocrine conditions are also known to cause secondary hyperhidrosis including diabetes mellitus, acromegaly, hyperpituitarism, pheochromocytoma and various forms of thyroid disease.

Medications

Use of selective serotonin reuptake inhibitors is a common cause of medication-induced secondary hyperhidrosis. Other medications associated with secondary hyperhidrosis include tricyclic antidepressants, stimulants, opioids, nonsteroidal anti-inflammatory drugs, glyburide, insulin, anxiolytic agents, adrenergic agonists, and cholinergic agonists.

Miscellaneous

Symmetry of excessive sweating in hyperhidrosis is most consistent with primary hyperhidrosis. To diagnose this condition, a dermatologist gives the person a physical exam. This includes looking closely at the areas of the body that sweat excessively. A dermatologist also asks very specific questions. This helps the physician understand why the person has excessive sweating. Sometimes medical testing is necessary. Some patients require a test called the sweat test. This involves coating some of their skin with a powder that turns purple when the skin gets wet.
Excessive sweating affecting only one side of the body is more suggestive of secondary hyperhidrosis and further investigation for a neurologic cause is recommended.

Treatment

Antihydral cream is one of the solutions prescribed for hyperhidrosis for palms. Topical agents for hyperhidrosis therapy include formaldehyde lotion and topical anticholinergics. These agents reduce perspiration by denaturing keratin, in turn occluding the pores of the sweat glands. They have a short-lasting effect. Formaldehyde is classified as a probable human carcinogen. Contact sensitization is increased, especially with formalin. Aluminium chlorohydrate is used in regular antiperspirants. However, hyperhidrosis requires solutions or gels with a much higher concentration. These antiperspirant solutions or hyperhidrosis gels are especially effective for treatment of axillary or underarm regions. It takes three to five days to see improvement. The most common side-effect is skin irritation. For severe cases of plantar and palmar hyperhidrosis, there has been some success with conservative measures such as higher strength aluminium chloride antiperspirants. Treatment algorithms for hyperhidrosis recommend topical antiperspirants as the first line of therapy for hyperhidrosis. The International Hyperhidrosis Society has published evidence-based treatment guidelines for focal and generalized hyperhidrosis.
Prescription medications called anticholinergics, often taken by mouth, are sometimes used in the treatment of both generalized and focal hyperhidrosis. Anticholinergics used for hyperhidrosis include propantheline, glycopyrronium bromide or glycopyrrolate, oxybutynin, methantheline, and benzatropine. Use of these drugs can be limited, however, by side-effects, including dry mouth, urinary retention, constipation, and visual disturbances such as mydriasis and cycloplegia. For people who find their hyperhidrosis is made worse by anxiety-provoking situations, taking an anticholinergic medicine before the event may help. In 2018, the U.S. Food and Drug Administration approved the topical anticholinergic glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis.
For peripheral hyperhidrosis, some people have found relief by simply ingesting crushed ice water. Ice water helps to cool excessive body heat during its transport through the blood vessels to the extremities, effectively lowering overall body temperature to normal levels within ten to thirty minutes.

Procedures

Injections of botulinum toxin type A can be used to block neural control of sweat glands. The effect can last from 3–9 months depending on the site of injections. This use has been approved by the U.S. Food and Drug Administration. The duration of the beneficial effect in primary palmar hyperhidrosis has been found to increase with repetition of the injections. The Botox injections tend to be painful. Various measures have been tried to minimize the pain, one of which is the application of ice.
This was first demonstrated by Khalaf Bushara and colleagues as the first nonmuscular use of BTX-A in 1993. BTX-A has since been approved for the treatment of severe primary axillary hyperhidrosis, which cannot be managed by topical agents.
miraDry, a microwave-based device, has been tried for excessive underarm perspiration and appears to show promise. With this device, rare but serious side effects exist and are reported in the literature, such as paralysis of the upper limbs and brachial plexus.
Tap water iontophoresis as a treatment for palmoplantar hyperhidrosis was originally described in the 1950s. Studies showed positive results and good safety with tap water iontophoresis. One trial found it decreased sweating by about 80%.

Surgery

Sweat gland removal or destruction is one surgical option available for axillary hyperhidrosis. There are multiple methods for sweat gland removal or destruction, such as sweat gland suction, retrodermal curettage, and axillary liposuction, Vaser, or Laser Sweat Ablation. Sweat gland suction is a technique adapted for liposuction.
The other main surgical option is endoscopic thoracic sympathectomy, which cuts, burns, or clamps the thoracic ganglion on the main sympathetic chain that runs alongside the spine. Clamping is intended to permit the reversal of the procedure. ETS is generally considered a "safe, reproducible, and effective procedure and most patients are satisfied with the results of the surgery". Satisfaction rates above 80% have been reported, and are higher for children. The procedure brings relief from excessive hand sweating in about 85–95% of people. ETS may be helpful in treating axillary hyperhidrosis, facial blushing and facial sweating, but failure rates in people with facial blushing and/or excessive facial sweating are higher and such people may be more likely to experience unwanted side effects.
ETS side-effects have been described as ranging from trivial to devastating. The most common side-effect of ETS is compensatory sweating. Major problems with compensatory sweating are seen in 20–80% of people undergoing the surgery. Most people find the compensatory sweating to be tolerable while 1–51% claim that their quality of life decreased as a result of compensatory sweating." Total body perspiration in response to heat has been reported to increase after sympathectomy. The original sweating problem may recur due to nerve regeneration, sometimes as early as 6 months after the procedure.
Other possible side-effects include Horner's Syndrome, gustatory sweating and excessive dryness of the palms. Some people have experienced cardiac sympathetic denervation, which can result in a 10% decrease in heart rate both at rest and during exercise, resulting in decreased exercise tolerance.
Percutaneous sympathectomy is a minimally invasive procedure similar to the botulinum method, in which nerves are blocked by an injection of phenol. The procedure provides temporary relief in most cases. Some physicians advocate trying this more conservative procedure before resorting to surgical sympathectomy, the effects of which are usually not reversible.