Excess Sweating - Hyperhidrosis

Excess sweating - in this post I discuss the diagnosis and treatment options for hyperhidrosis.

Hyperhidrosis is common, it affects 1-3% of the population.

What are the important questions?

  • When it started,

  • Whether it runs in the family,

  • Where on the body the sweating occurs,

  • Whether it is symmetrical,

  • How troublesome,

  • Whether their is malodour, in what situations,

  • Whether it occurs at night and

  • What the patient has tried?

Primary hyperhidrosis is the likely diagnosis when focal, visible, excessive sweating occurs in at least one of the following places:

Armpits (axillae), palms, soles, or head and face (craniofacial)

AND

Has lasted at least 6 months

AND

Has no apparent cause

AND

Has at least two of the following characteristics:

  • Bilateral and relatively symmetrical.

  • Impairs daily activities.

  • Happens at least once per week.

  • Started before 25 years of age.

  • Has happened in someone else in the direct family

  • The local sweating stops when the patient sleeps.

When should the doctor take extra care with the diagnosis?

If the problem has lasted less than 6 months or started after 25 years of age, primary focal hyperhidrosis remains a likely diagnosis if other criteria are met, but the doctor should take extra care to exclude an underlying cause.

If the presentation is characteristic of primary focal hyperhidrosis and there is no evidence of an underlying cause, no laboratory tests are needed.

Patients are often seen by their general practitioner, who will consider whether it is primary hyperhidrosis and they will be perfectly capable of offering support and treatment. If things are more difficult, treatment has not helped or the doctor is not sure, the patient might be referred onto a specialist.

Endocrinologists are one of those specialists, sometimes a dermatologist is consulted and rarely a surgeon might be the person to help.

Why might a patient see an endocrinologist?

The endocrinologists job is often to consider if it is due to some other cause - secondary hyperhidrosis.

In particular endocrine or metabolic disorders or conditions:

  • thyrotoxicosis

  • hypoglycaemia

  • phaeochromocytoma

  • carcinoid tumour

  • pituitary disease eg acromegaly

  • obesity

  • gout

  • testosterone deficiency

  • the menopause.

But there is a lot more to it than that, infections, heart or lung disease, neurological conditions such as strokes or Parkinson's, pregnancy, anxiety, prescribed or recreational drugs and alcohol, and alcohol withdrawal, can all be associated with sweating, so the doctor must make a thorough assessment of the patient.

What about treatment?

Most patients will have primary focal hyperhidrosis, and will consider helping their symptoms with antiperspirants. It is very important to distinguish deodourants from antiperspirants, and it is the latter that patients will benefit from most.

Lifestyle advice.

The following are sensible recommendations for all people with primary focal hyperhidrosis:

- Modify behaviour to avoid identified triggers if possible e.g. crowded rooms, caffeine, or spicy foods.

For people with primary axillary hyperhidrosis:

- Use an over the couner antiperspirant (as opposed to a deodorant) frequently

- Avoid tight clothing and manmade fabrics

- White (as opposed to blue) shirts or black clothing help minimize the signs of sweating.

- Consider trying dress shields (aka armpit or sweat shields) to absorb excess sweat and protect expensive or delicate clothing. These can be obtained via the internet or the Hyperhidrosis Support Group http://www.hyperhidrosisuk.org/

For people with primary plantar hyperhidrosis:

- Wear moisture-wicking socks, change them at least twice daily.

- Use absorbent soles, and use absorbent foot powder twice daily.

- Avoid footwear that does not breath well such as boots or sports shoes; wear leather shoes.

- Let shoes dry out fully, alternate pairs of shoes on a daily basis before wearing them again.

For people with primary face & neck (craniofacial) hyperhidrosis:

- Avoid food and drink triggers if possible, if they exacerbate symptoms - including caffeinated products, alcohol, foods or drinks containing citric acid, or sweets, chocolate, hot, sour or spicy foods).

Specific therapy

The first line, and useful, treatment for hyperhidrosis is:

20% aluminium chloride hexahydrate

and this is in treatments such as Driclor® and Anhydrol Forte® which can be prescribed or bought over the counter.

It should be applied to the axillae, palms, soles, groin or face (avoiding the eyes), on skin that is bone dry, at night and washed off in the morning. This is done every one - two days (as tolerated) until things improve, then as required.

The patient should not shave for one to two days after application.

Aluminium chloride can cause skin irritation; if so reduce the frequency of application, avoid soap, use a soap substitute and emolient, and this should be mentioned to the doctor, anti-inflammatory creams, such as hydrocortisone can help settle the skin down.

Pads can be soaked before application to the face and dusting powder (Zeasorb®) can be used on the feet.

Enormous social and psychological discomfort can be caused by hyperhidrosis, and it is important for some patients that supporting them with their symptoms is considered.

Anxiety is common and should be considered and treated; it can be a cause of hyperhidrosis, or a consequence, and psychological support and/or cognitive behaviour therapy can help if it occurs in certain situations. Antidepressants and beta-blockers (propranolol) can make sweating worse.

If things are still troublesome an endocrinologist who has seen and assessed many patients with hyperhidrosis may still be able to support the patient, or a dermatologist is often consulted.

There are stronger topical preparations that can be tried, such as 50% aluminium chloride solutions.

Iontophoresis is effective, it is offered on the NHS in many areas of the country and is useful for parts of the body that can be immersed in water - through which an electrical current is applied. Kits can be bought over the counter to do it at home but it is usually started in hospital under supervision on the condition it will be continued at home, with a machine the patient purchases their self, if it is effective.

Botulinum toxin can be administered by trained specialists, and Botox® is licensed for use in axillary hyperhidrosis. It can have side effects, appropriately discussed, before treatment, with the specialist. It is not often available on the NHS, usually being given in private clinics.

Medications can be tried including antimuscarinic drugs such as oxybutinin or glycopyrolate (Robinul®), the calcium channel blocker diltiazem, clonidine or benzodiazepines, all under supervision.

Surgery is necessary for some patients. This may involve removing the sweat glands from the axillae, but it is complex and can cause scarring. Interrupting the nervous supply to the sweat glands is a last resort, only considered by very skilled surgeons (usually vascular surgeons) by an endoscopic procedure at the base of the neck, side effects are common and troublesome.

It is important the patient's symptoms are properly assessed, secondary causes considered, if relevant, by an appropriately trained specialist, anxiety is considered and treated if present and prompt effective advice and therapy provided if necessary, reviewing after one to two months.

Let patients know about the support societies

- The Hyperhidrosis Support Group at www.hyperhidrosisuk.org

- The International Hyperhidrosis Society at www.sweathelp.org

If the post is useful please share and/ or leave comments.

Every effort is made to ensure that this health and medication advice is accurate and up to date. It is for information only and supports your consultation it does not obviate the need for that consultation and should not replace a visit to your doctor or health care professional.

The written advice is general in nature and in is not specific to individual patients and Dr Philip Kelly cannot accept any liability for actions arising from its use nor can he be held responsible for the content of any pages contained in any external link.

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Dr Philip Kelly & Dr Martin Whyte
King's Private, The Guthrie Wing,

King's College Hospital

London SE5 9RS

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Dr Philip Kelly
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