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Hyperhidrosis
Mohan Gamesh
 Contents
• Physiology of sweating
• Introduction
• Pathophysiology of
excessive sweating
• Etiology
• Signs & Symptoms
• Diagnosis
• Treatment
 Physiology of sweating
• Sweating is regulated by the sympathetic division of the
autonomic nervous system.

• Its major role is to prevent overheating of the body.

(http://www.sweathelp.org/English/HCP_Hyperhidrosis_Physiology.asp)
 Physiology of sweating

• Heat induced sweating

 begins on the forehead and then spreads inferiorly over the
remainder of the body

• Emotionally induced sweating

 “cold sweat” brought on by fright, embarrassment, or
nervousness
 begins on the palms, soles, and axillae and then spreads to
other body areas
 Introduction

Hyperhidrosis

“is a disease characterized by

perspiration in excess of the
physiologic amount necessary to
maintain thermal homeostasis”
Pathophysiology of excessive sweating
• Sweat glands in patients with hyperhidrosis are NOT:
 histopathologically different from those in normal patients
 nor is there an increase in the number or size of glands

• The condition is caused by hyperfunction of the sweat

glands rather than hypertrophy
Pathophysiology of excessive sweating
• Patients with primary hyperhidrosis have:
 a higher-than-normal basal level of sweat
production

 an increased response to normal stimuli such as

emotional or physical stress
http://www.sweathelp.org/English/HCP_Hyperhidrosis_Pathophysiology.asp
 Etiology

Hyperhidrosis

Primary Secondary
 Etiology
• Patients can have excessive sweating either in:
 localized area (focal) or
 over the entire body (generalized)

• Primary disease is usually focal

• Secondary hyperhidrosis can be

generalized or focal
 Focal sweating
• Emotional causes are common

• Sweating on the palms, soles, axillae, and

forehead
 at times of anxiety, excitement, anger, or fear

• It may be due to a generalized stress

 ↑ sympathetic outflow
 Focal sweating
• Gustatory sweating occurs around the lips and mouth when
ingesting foods and beverages that are spicy or hot in
temperature

• There is no known cause in most cases, but gustatory

sweating can be increased in:
 diabetic neuropathy
 facial herpes zoster
 cervical sympathetic ganglion invasion
 CNS injury or disease or
 parotid gland injury
 Focal sweating
• In the case of parotid gland injury, surgery, infection, or
trauma may:
 disrupt parotid gland innervation and

 lead to regrowth of parotid parasympathetic fibers into

sympathetic fibers innervating local sweat glands in skin
where the injury took place, usually over the parotid gland

 This condition is called Frey's syndrome

Frey's syndrome
 Focal sweating
• Other causes of focal sweating include:
 pretibial myxedema (shins)
 hypertrophic osteoarthropathy (palms)
 blue rubber bleb nevus syndrome and glomus tumor (over
lesions)

• Compensatory sweating is intense sweating after

sympathectomy
 Generalized sweating
• Generalized sweating involves most of the
body

• Although most cases are

idiopathic, numerous
conditions can be
involved
 Signs and Symptoms
• Sweating is often present during physical
examination and sometimes is extreme

• Clothing can be soaked, and palms or soles

may become macerated and fissured
 Signs and Symptoms
• Hyperhidrosis can cause emotional distress
to those who have it and may lead to social
withdrawal

• Palmar or plantar skin may appear pale

 Diagnosis
• History and examination

• Iodine and starch test

• Tests to identify a cause

 Diagnosis

•Iodine and starch test:

Apply iodine solution

to the affected area,
let dry, dust on corn starch:
areas of sweating appear dark
 Diagnosis
• Testing is necessary only to:

 confirm foci of sweating

 (as in Frey's syndrome or to locate the area
needing surgical or botulinum toxin treatment) or

 in a semi-quantitative way when following the

course of treatment
Half way gone!
 Diagnosis
• Tests to identify a cause of hyperhidrosis are guided by a
review of symptoms and might include:

 CBC – detect leukemia

 Plasma glucose – detect diabetes

 Thyroid-stimulating hormone
– screen for thyroid dysfunction
 Effects on Patients' Lives
• Hyperhidrosis can have
very significant effects
causing:

 physical discomfort
 social embarrassment
 negative impact on occupational and
daily activities
 Effects on Patients' Lives

• Score of 1 or 2 indicates mild or moderate hyperhidrosis

• Score of 3 or 4 indicates severe hyperhidrosis
• Post-treatment, as part of a measurement of treatment efficacy and patient
satisfaction
• 1-point improvement in score – 50% reduction in sweat production
• 2-point improvement in score – 80% reduction in sweat production
 Treatment
• Aluminum chloride hexahydrate solution

• Tap water iontophoresis

• Botulinum toxin type A

• Surgery

• Antimuscarinic agents
(propantheline bromide)

• Absorbants (talc)

• Psychological (CBT)
 Aluminum chloride hexahydrate
solution
• 6 to 20% solution in absolute ethyl alcohol
 indicated for topical treatment of axillary, palmar, and
plantar sweating (require a prescription)

• The solution blocks sweat ducts

• Most effective when applied nightly and covered tightly

with a thin polyvinylidene or polyethylene film;

• Should be washed off in the morning

 Aluminum chloride hexahydrate
solution
• Sometimes an anticholinergic drug is taken before
applying
 to prevent sweat from washing the aluminum chloride
away

• Initially, several applications weekly are needed to achieve

control, then a maintenance schedule of once or twice
weekly is followed
 Aluminum chloride hexahydrate
solution
• This solution SHOULD NOT be applied to
inflamed, broken, wet, or recently shaved skin

• High-concentration, water-based aluminum

chloride solutions may provide adequate relief in
milder cases
 Aluminum chloride hexahydrate
solution
• Topical alternatives to aluminum chloride are
effective but can cause contact dermatitis and skin
discoloration

 Glutaraldehyde
 Formaldehyde
 Tannic acid
 Aluminum chloride hexahydrate
solution
• A solution of methenamine also may help

 polycyclic organic compound which release ammonia and

formaldehyde at acid pH

 5% methenamine in a firm stick gel, applied daily to one

palmar or plantar surface of patients with hyperhidrosis,
resulted in significantly less sweating
 Tap water iontophoresis
• Salt ions are introduced into the skin using electric current,
is an option for patients unresponsive to topical treatments

• The affected areas (typically palms or soles) are placed in

2 tap water basins

• Each containing an electrode across which a 15- to 25-mA

current is applied for 10 to 20 min
 Tap water iontophoresis
• This routine is done daily for 1 week and then repeated
weekly or bimonthly

• Treatments may be made more effective with topical or

oral anticholinergic drugs

• Although the treatments are usually effective, the

technique is time-consuming, cumbersome, and a tiring
routine
 Botulinum toxin type A
• A neurotoxin
 ↓ the release of acetylcholine from
sympathetic nerves serving eccrine glands

• Injected directly into the axillae, palms, or

forehead
 inhibits sweating for about 5 mo depending
on dose
 Botulinum toxin type A
• Complications include local muscle
weakness and headache

• Injections are effective but painful and

expensive
 Surgery
• Indicated if more conservative treatments fail

• Patients with axillary sweating can be treated with

 surgical excision of axillary sweat glands
 through open dissection or by liposuction

• Those with palmar sweating can be treated with

endoscopic transthoracic sympathectomy (ETS)
 Surgery
• The potential morbidity of surgery must be
considered, especially in sympathectomy

• Potential complications include:

 Phantom sweating
 Compensatory sweating
 Gustatory sweating
 Neuralgia
 Horner's syndrome
Merci!!!
 References
• International Hyperhydrosis
Society:
http://www.sweathelp.org/English/
HCP_Home.asp

• The Merck Manuals:

http://www.merckmanuals.com/pr
ofessional/sec10/ch118/ch118c.ht
ml?qt=hyperhidrosis&alt=sh