Hyperhidrosis is a physiological disorder of the sympathic nervous system characterized by excessive sweating beyond what is required to cool the body. Although not life-threatening, hyperhidrosis has psychological, social, and professional consequences, and can be disabling. Focal hyperhidrosis involves specific areas of the body, most commonly the hands, feet, axillae, and face.

Focal hyperhidrosis

The pathophysiology of focal hyperhidrosis is poorly understood and the etiology unknown.1 Symptoms arise from excessive secretion of the eccrine sweat glands, which are innervated by the cholinergic fibers of the sympathetic nervous system. A genetic predisposition may exist since up to 66% of symptomatic patients report another family member afflicted with hyperhidrosis.

The incidence of hyperhidrosis in the United States has been reported as 2.8% of the general population; it affects men and women equally, with the highest prevalence among 25- to 64-year-olds. The average age of onset is 25 years, however this can differ depending on the affected area. Palmar hyperhidrosis has the earliest average onset at age 13.2 Most patients do not seek treatment until adulthood.

Profuse, uncontrollable sweating can interfere with the recreational, social, academic, and professional aspects of one's life.3-5 Many patients are unable to develop or maintain intimate relationships, perform activities of daily living, work in certain jobs, and report a negative impact on health-related quality of life.6,7

Case study

V.H., a 38-year old, divorced female, presented with complaints of severe, spontaneous sweating on her hands and underarms. Symptoms had been present for as long as she could remember. She had no illnesses and took no medications. There were no known allergies. Her only surgery was a tonsillectomy at age 6. She did not smoke or drink alcohol, and denied use of illicit drugs.

Family history revealed that her mother had hypertension, her father died of heart failure, and her sister had excessive sweating of the hands and feet. A detailed review of systems was positive for anxiety, depression, frequent crying, and social isolation. Further discussion revealed that she only left her home at night.

She had quit her job as a bank teller 2 years prior because money, documents, and checks became soaked with sweat from her hands. She stopped attending church services because hand holding was part of the ceremony. Despite use of numerous over-the-counter antiperspirants, her clothes would become soaked from the axilla down to her waist; sweat would often run down her arms and drip out the sleeves of her shirt. She was functionally impaired, unable to perform many activities of daily living, such as blow drying her hair since the hair dryer would slip out of her hands. Her brief marriage ended in divorce because she was unable to maintain an intimate relationship.

Her anxiety and depression had been treated with anxiolytics and antidepressants by a psychiatrist 5 years prior, however, she discontinued all medications and counseling after a year since she saw no improvement in her function or sweating. She had mentioned her symptoms to her previous primary care provider, however, no specific treatment had been recommended. Current laboratory studies revealed results of a complete blood count, comprehensive metabolic panel, and thyroid stimulating hormone (TSH) to be within the limits of normal.

Diagnosis

A complete history and physical exam are important first steps in the evaluation of excessive sweating. If the symptoms are characteristic of primary focal hyperhidrosis, the diagnosis can be made and does require laboratory testing.3 However, in the absence of other causes, such as hyperpituitarism, diabetes mellitus, and spinal cord injury, a TSH is often obtained to evaluate for hyperthyroidism as a cause.

Once the diagnosis is made, the severity of hyperhidrosis should be determined. The Hyperhidrosis Disease Severity Scale (HDSS) is a qualitative measure of the severity of the patient's condition based on the effect on activities of daily living (see Hyperhidrosis disease severity scale).1 The results of this single-item instrument can be used to guide treatment.

Treatment options

For mild or moderate symptoms, topical aluminum chloride (AC) hexahydrate is the initial treatment. This solution is applied topically to the affected area at bedtime every 24 to 48 hours. If topical treatment is ineffective or causes skin irritation, tap-water iontophoresis can be considered. This method uses a device that provides direct current of 15 to 20 mA to the affected area. It is used three to four times per week for 20 to 30 minutes until euhidrosis is achieved, usually after 6 to 10 treatments, at which time the frequency can be titrated as needed to control sweating. For persistent sweating, intradermal injection of botulinum toxin A (BTA) into the affected area is available. If effective, the injections can be repeated every 4 to 6 months as needed to control sweating.

For severe hyperhidrosis, AC, iontophoresis, or BTA are all first-line treatment options, which can be used in combination if the patient fails to respond to monotherapy. Additionally, glycopyrrolate (Robinul) can be prescribed off-label up to three times a day if the other modalities are ineffective.

Endoscopic thoracic sympathectomy (ETS) is an option for patients with severe hyperhidrosis whose symptoms do not respond to maximal nonsurgical therapy. However, the patient must understand that the potential for permanent side effects exists following ETS. The most frequent side effect is compensatory hyperhidrosis, which occurs on the trunk and legs in up to 86% of patients.8 Horner's syndrome, which results in permanent miosis and ptosis of the affected eye, has been reported in 1% to 2% of patients treated with ETS.3 Other less common, but known risks of the surgery include intercostal neuralgia, hemothorax, and pneumothorax.

Discussion

V.H. had an HDSS score of 4, indicating severe hyperhidrosis. AC topical therapy was prescribed and applied as directed for 1 week, but was discontinued after the she developed severe irritation and cracking of the skin. She used an iontophoresis device for 4 weeks (16 treatments), however her severe sweating persisted. She declined BTA injections because of the high expense. Glycopyrrolate was gradually titrated from daily to three times a day over a 4-week period, however, profuse sweating persisted. After 9 weeks of dedicated treatment, she was referred to a neurosurgeon for consideration of ETS.

A bilateral ETS was performed as an outpatient procedure. Upon awaking from anesthesia, she immediately noticed her underarms and hands were completely dry. At her 2-week postoperative visit, she continued to enjoy resolution of her axillary and hand sweating. V.H. noticed compensatory sweating on her back in climate temperatures over 85 [degrees]F (29 [degrees]C), which she rated as mild and not bothersome.

At 2-year follow-up, V.H. reported complete resolution of her underarm and hand sweating. She experienced mild compensatory hyperhidrosis in the summer months, yet still rated her overall satisfaction with ETS as extremely satisfied. She reported she now enjoyed normal activities of daily living and relationships.

Patients presenting with symptoms of hyperhidrosis can pose a diagnostic and therapeutic challenge. Recognizing the symptoms, making the diagnosis, and offering effective treatment can dramatically improve a patient's quality of life.

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