Hyperhidrosis: Current Understanding, Current Therapy :
Authors: Markus Naumann, MD; Jonathan R.T. Davidson, MD; Dee Anna Glaser, MD
Preface: The Patient’s Perspective
Lisa dates her problem with hyperhidrosis to her sophomore year of high school. It probably started a bit earlier, she thinks, but a humiliating experience during her Oral Communications class marks the symbolic beginning of her struggle with hyperhidrosis. After literally sweating through an oral presentation in front of the class, she heard a fellow student mutter in disgust, “Oh my God, look at her. Look at how bad she’s sweating.” Lisa still finds the memory painful.
Being a 15-year-old girl is tough, but being a 15-year-old girl with hyperhidrosis is tougher. The fun of being a cheerleader was overshadowed by the turmoil of constantly worrying about how much she was sweating. She worked up the courage to tell her parents, but they didn’t really understand. “I didn’t even know that prescription antiperspirants existed, and I was too young to take the situation into my own hands,” she remembers today at age 26. So she changed clothes 3 times a day, stuffed tissues, napkins, and paper towels in her armpits, and blamed herself. And that’s how she coped with hyperhidrosis for the next 8 years.
A newsmagazine show was on the TV, but Lisa wasn’t paying much attention. Then she realized that the woman being interviewed was talking about her constant battle with sweating. “My head just spun around,” remembers Lisa. “I thought it was just me, and so I blamed myself. Then I saw this woman on TV and I realized, I’m not the only one.”
And so at age 23 Lisa worked up the courage to see a doctor. He prescribed an antiperspirant, but it didn’t help. Three months later, she went to a different doctor and got a prescription for a different antiperspirant, but it didn’t help either. For the next 3 years, Lisa continued to perfect her routine for dealing with hyperhidrosis:
“I can’t buy nice clothes, because I have to throw them away after wearing them once or twice, especially white things. I probably spend 2 hours a day dealing with sweating — wiping, refreshening, showering, bathing, washing clothes — but I really spend more time than that because I never stop thinking about it. When I go to a club with my friends, the first thing I do is check out the bathroom. Are there plenty of paper towels for me to stuff in my armpits? Is there an air-dryer I can use to dry my armpits? I don’t take off my coat when I make presentations, and I never gesture with my hands — people would see the sweat stains that go halfway down my arms, or, even worse, the paper towels might fall out. I always keep my arms held close to my body. When I visit friends or relatives, I make sure I hug everyone before I take off my coat.”
Of course developing personal relationships has been difficult. Lisa has told only her parents — who now understand the condition and are supportive — and her boyfriend. But a favor Lisa recently did for her mother may hold the solution to her problem. Lisa’s mother had an appointment with a dermatologist, and Lisa gave her a ride and sat in on the consultation. At the end of the appointment, Lisa asked about sweating. The dermatologist turned out to be a recognized expert in hyperhidrosis, and Lisa will begin treatment soon.
Definition, Epidemiology, and Symptoms
Hyperhidrosis is excessive sweating. The simple qualitative definition of hyperhidrosis as excessive sweating is, of course, completely subjective. For research purposes, hyperhidrosis is defined quantitatively as the production of more than 100 mg of sweat in 1 axilla over 5 minutes.[1] Hyperhidrosis may be focal or generalized. Focal hyperhidrosis usually affects the axillae, palms, soles of the feet, face, and, rarely, other areas.
It can be extremely disabling in both private and professional life. Focal hyperhidrosis affects up to 0.5% of the population and usually appears during the second or third decade of life. Focal hyperhidrosis is most often essential, or idiopathic, and results from a neurogenic overactivity of the sweat glands in the affected area. The palms and/or soles of the feet (palmoplantar hyperhidrosis) are affected in about 60% of patients, and the axillae are affected in 30% to 40%.[2] Facial sweating is less frequent and affects up to 10% of patients with idiopathic hyperhidrosis.
Facial hyperhidrosis should be distinguished from gustatory sweating, which is a secondary form of hyperhidrosis that occurs on the cheek in response to salivation or anticipation of food. While focal hyperhidrosis is psychologically distressing and anxiety can trigger sweating, the condition is only rarely associated with psychiatric disorders. Patients with focal hyperhidrosis have a physiologic condition, not a psychiatric disorder. Hyperhidrosis can, however, be secondary to social anxiety disorder. (See “Psychiatric Aspects of Hyperhidrosis,” below.)
Focal hyperhidrosis also may be secondary to spinal cord injury and some polyneuropathies. Ross syndrome is a rare form of focal hyperhidrosis of unknown etiology characterized by progressive anhidrosis due to degeneration of sudomotor fibers. There may be disabling compensatory hyperhidrosis in areas in which sudomotor fibers remain intact (mostly the trunk, sometimes the extremities, neck, and face). Generalized hyperhidrosis, in which sweating occurs over the whole body, has many causes, including diabetes, chronic infectious diseases, and malignancy. The consequences of hyperhidrosis include dehydration and maceration of the skin, which may result in secondary skin infections.
Neurobiology of Sweating
The human body has an estimated 2-4 million eccrine glands[3] which play an important role in cooling the body in response to increased body temperature (Figure 1). The secretion of eccrine sweat involves the secretion of an ultrafiltrate by the secretory coil in response to acetylcholine (which is released from the sympathetic nerve endings) and reabsorption of sodium by the ductal portion so that the surface sweat is hypotonic.[4] When perspiration is heavy, this absorptive function is crucial for the conservation of electrolytes. The eccrine sweat gland does excrete other compounds, such as heavy metals and organic compounds.
Pathophysiology of Hyperhidrosis
The cause of essential focal hyperhidrosis is unknown at present. The sweat glands and their innervation do not show any histologic abnormalities. A dysfunction of the central sympathetic nervous system, possibly of hypothalamic nuclei, or prefrontal areas or their connections is suspected.[5,6] Sufferers display no other signs or symptoms of autonomic dysfunction. A positive family history for the condition in 30% to 50% of cases suggests a genetic component.[7] Gustatory sweating may result from misdirection of autonomic nerves fibers after surgery or in diseases of the parotid gland, and may occur in diabetes and some other rare conditions. Generalized hyperhidrosis can be secondary to a variety of conditions including metabolic disease such as diabetes or hyperthyroidism; chronic infections like tuberculosis; alcoholism; and malignancy.




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