Hyperhidrosis

1. Pathophysiology
   1. Cerebral cortex releases stimuli secondary to emotion
   2. Hypothalamus is hypersensitive to these stimuli
   3. Results in Eccrine Gland hypersecretion
      1. Eccrine Glands are normal
2. Symptoms
   1. Excessive sweating palms and soles
   2. Exacerbated by stress or anxiety
   3. Only occurs while awake
3. Differential Diagnosis
   1. Hyperthyroidism
   2. Cholinergic agent exposure
   3. Lymphoma
   4. Hypoglycemia
   5. Pheochromocytoma
   6. Horner's Syndrome
   7. Tuberculosis
   8. Lymphoma
   9. Drug Withdrawal
4. Management
   1. Bedtime technique: First-line, preferred option
      1. Apply topical (Drysol) 2-3 times per week at bedtime
      2. Apply Occlusive Dressing over night
      3. Remove in the morning and wash off
      4. Apply baking soda to skin to reduce irritation
   2. Topical Preparations
      1. Aluminum chloride hexahydrate 20% (Drysol, Xerac)
         1. Obstruct Eccrine Gland pores
         2. Results in atrophy of Sweat Gland secretory cells
      2. Other agents with lower efficacy
         1. Zeasorb Powder (Miconazole)
         2. Boric acid
         3. Topical anticholinergic agents
         4. Tannic acid
         5. Numerous others (Formaldehyde, Glutaraldehyde)
   3. Systemic Preparations
      1. Anticholinergics (Not recommended for longterm use)
         1. Glycopyrrolate (Robinul)
         2. Phenoxybenzamine (Dibenzyline)
      2. Medications to reduce anxiety (low efficacy)
         1. Serzone
         2. Imipramine
         3. Propranolol
         4. Benzodiazepines
            1. Not recommended due to dependency risk
   4. Tap water Iontophoresis
      1. Safe, effective and well tolerated since the 1950s
      2. Galvanic current 15-20 mA applied to intact skin
         1. Applied to each palm or sole
         2. Apply current for 30 minutes each for 10 days
         3. Uses tap water
      3. Adjuncts (increase efficacy)
         1. Aluminum Chloride hexahydrate (Drysol)
         2. Atropine (limit to 1 mg per 30 cc tap water)
   5. Surgical Interventions (Refractory, severe cases)
      1. Botulinum Toxin Type A (Botox) local injection
         1. Safe and effective
         2. Expensive ($1500 for both hands repeated q6 months)
         3. Regional anesthesia (Median and Ulnar Nerve Block)
         4. Preferred option for axillary Hyperhidrosis
         5. Serial intracutaneous injections
            1. Each injection spaced 0.5 to 2 cm apart
            2. Anhidrosis at each site persists 4-13 months
      2. Endoscopic sympathectomy
         1. Surgical destruction of sympathetic ganglia
            1. Palmar: third thoracic ganglia (T3)
            2. Plantar: Not done due to sexual dysfunction
               1. Improves with 50% of T4 sympathectomy
               2. Consider iotophoresis as alternative
         2. Indications
            1. Method of last resort for severe Hyperhidrosis
            2. Case refractory to other measures
            3. Highly effective for palmar Hyperhidrosis
         3. Relative contraindications
            1. Axillary Hyperhidrosis (T4) due to poor efficacy
            2. Face, scalp Hyperhidrosis (T2)
               1. Due to very high risk of compensatory sweating
         4. Adverse effects and complications
            1. Compensatory sweating
               1. Trunk, groin, thighs and popliteal fossa
               2. Severe in 50% if T2 sympathectomy
               3. Severe in 19% if only T3 sympathectomy
               4. Clip removal may alleviate symptoms
            2. Gustatory sweating
               1. Sweating at back of neck when eating spicy food
               2. May follow T2 sympathectomy
               3. Also seen with Diabetic Autonomic Neuropathy
            3. Injury to adjacent structures during surgery
               1. Pneumothorax, Pneumonia, Pneumothorax
               2. Horner's Syndrome
5. Resources
   1. International Hyperhidrosis Society
      1. http://www.sweathelp.org
6. References
   1. Rakel (2002) Family Practice, Saunders, p. 1003-4
   2. Ferri (2004) Clinical Advisor, p. 1069
   3. Thomas (2004) Am Fam Physician 69(5):1117-21
   4. Stolman (1998) Dermatol Clin 16:863-9
   5. Linn (1998) Eur J Surg, Suppl 580:13