sign in sign up
<<
Home , Hyperhidrosis

Clinical Case Report

Diagnosis and treatment of

Katherine Kenny, RN, ANP-BC, CCRN, DNP intimate relationships, perform activi- out of her hands. Her brief marriage ties of daily living, work in certain ended in divorce because she was Hyperhidrosis is a physiological disor- jobs, and report a negative impact on unable to maintain an intimate rela- der of the sympathic nervous system health-related quality of life.6,7 tionship. characterized by excessive sweating Her and depression had beyond what is required to cool the ■ Case study been treated with and anti- body. Although not life-threatening, V.H., a 38-year old, divorced female, depressants by a psychiatrist 5 years hyperhidrosis has psychological, so- presented with complaints of severe, prior, however, she discontinued all cial, and professional consequences, spontaneous sweating on her hands medications and counseling after a and can be disabling. Focal hyper- and underarms. Symptoms had been year since she saw no improvement hidrosis involves specific areas of the present for as long as she could re- in her function or sweating. She had body, most commonly the hands, member. She had no illnesses and mentioned her symptoms to her pre- feet, axillae, and face. took no medications. There were no vious primary care provider, however, known allergies. Her only surgery was no specific treatment had been rec- ■ a tonsillectomy at age 6. She did not ommended. Current laboratory stud- The pathophysiology of focal hyper- smoke or drink alcohol, and denied ies revealed results of a complete hidrosis is poorly understood and the use of illicit drugs. blood count, comprehensive meta- etiology unknown.1 Symptoms arise Family history revealed that her bolic panel, and stimulating from excessive secretion of the eccrine mother had hypertension, her father hormone (TSH) to be within the sweat glands, which are innervated by died of , and her sister limits of normal. the fibers of the sympa- had excessive sweating of the hands thetic nervous system. A genetic pre- and feet. A detailed ■ Diagnosis disposition may exist since up to was positive for anxiety, depression, A complete history and physical 66% of symptomatic patients report frequent crying, and social isolation. exam are important first steps in the another family member afflicted with Further discussion revealed that she evaluation of excessive sweating. If hyperhidrosis. only left her home at night. the symptoms are characteristic of The incidence of hyperhidrosis in She had quit her job as a bank primary focal hyperhidrosis, the diag- the United States has been reported teller 2 years prior because money, nosis can be made and does require as 2.8% of the general population; it documents, and checks became laboratory testing.3 However, in the affects men and women equally, with soaked with sweat from her hands. absence of other causes, such as the highest prevalence among 25- to She stopped attending church services , mellitus, 64-year-olds. The average age of onset because hand holding was part of the and spinal cord injury, a TSH is often is 25 years, however this can differ de- ceremony. Despite use of numerous obtained to evaluate for hyperthy- pending on the affected area. Palmar over-the-counter antiperspirants, roidism as a cause. hyperhidrosis has the earliest average her clothes would become soaked Once the diagnosis is made, the onset at age 13.2 Most patients do not from the axilla down to her waist; severity of hyperhidrosis should be seek treatment until adulthood. sweat would often run down her determined. The Hyperhidrosis Profuse, uncontrollable sweating arms and drip out the sleeves of her Disease Severity Scale (HDSS) is a can interfere with the recreational, shirt. She was functionally impaired, qualitative measure of the severity of social, academic, and professional unable to perform many activities of the patient’s condition based on the aspects of one’s life.3-5 Many patients daily living, such as blow drying her effect on activities of daily living (see are unable to develop or maintain hair since the hair dryer would slip Hyperhidrosis disease severity scale).1

10 The Nurse Practitioner • Vol. 34, No. 7 www.tnpj.com Clinical Case Report

The results of this single-item instru- ment can be used to guide treatment. Hyperhidrosis disease severity scale

■ Treatment options My sweating is never noticeable and Score 1 never interferes with my daily activities. For mild or moderate symptoms, topical aluminum chloride (AC) My sweating is tolerable but sometimes Score 2 hexahydrate is the initial treatment. interferes with my daily activities. This solution is applied topically to My sweating is barely tolerable and frequently Score 3 the affected area at bedtime every interferes with my daily activities. 24 to 48 hours. If topical treatment My sweating is intolerable and always Score 4 is ineffective or causes skin irritation, interferes with my daily activities. tap-water can be con- sidered. This method uses a device that provides direct current of 15 to risks of the surgery include inter- her overall satisfaction with ETS as 20 mA to the affected area. It is used costal neuralgia, hemothorax, and extremely satisfied. She reported she three to four times per week for 20 pneumothorax. now enjoyed normal activities of daily to 30 minutes until euhidrosis is living and relationships. achieved, usually after 6 to 10 treat- ■ Discussion Patients presenting with symptoms ments, at which time the frequency V.H. had an HDSS score of 4, indicat- of hyperhidrosis can pose a diagnos- can be titrated as needed to control ing severe hyperhidrosis. AC topical tic and therapeutic challenge. Recog- sweating. For persistent sweating, therapy was prescribed and applied nizing the symptoms, making the intradermal injection of botulinum as directed for 1 week, but was discon- diagnosis, and offering effective toxin A (BTA) into the affected area tinued after the she developed severe treatment can dramatically improve is available. If effective, the injections irritation and cracking of the skin. a patient’s quality of life. can be repeated every 4 to 6 months She used an iontophoresis device for as needed to control sweating. 4 weeks (16 treatments), however her REFERENCES 1. Solish N, Bertucci V, Dansereau A, et al. A com- For severe hyperhidrosis, AC, severe sweating persisted. She declined prehensive approach to the recognition, diag- iontophoresis, or BTA are all first-line BTA injections because of the high nosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian treatment options, which can be used expense. Glycopyrrolate was gradually Hyperhidrosis Advisory Committee.Dermatologic in combination if the patient fails to titrated from daily to three times a day Surgery. 2007;33(8):908-923. 2. Strutton R, Kowalski J, Glaser D, Stang P. U.S. respond to monotherapy. Addition- over a 4-week period, however, profuse prevalence of hyperhidrosis and impact on indi- ally, glycopyrrolate (Robinul) can sweating persisted. After 9 weeks of viduals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. 2004;51(2): be prescribed off-label up to three dedicated treatment, she was referred 241-248. times a day if the other modalities to a neurosurgeon for consideration 3. Hornberger J,Grimes K,Naumann M,et al.Recog- are ineffective. of ETS. nition, diagnosis and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004;51(2): Endoscopic thoracic sympathec- A bilateral ETS was performed as 274-286. tomy (ETS) is an option for patients an outpatient procedure. Upon awak- 4. Thomas I, Brown J, Vafaie J, Schwartz R. Palmo- plantar hyperhidrosis: a therapeutic challenge. with severe hyperhidrosis whose ing from anesthesia, she immediately American Family Physician. 2004;69(5):1117-1120. symptoms do not respond to maximal noticed her underarms and hands 5. Glaser D, Hebert A, Pariser A, Solish N. Primary focal hyperhidrosis: scope of the problem. Cutis. nonsurgical therapy. However, the were completely dry. At her 2-week 2007;79(5 suppl):5-17. patient must understand that the postoperative visit, she continued to 6. Haider A, Solish N. Focal hyperhidrosis: diagno- potential for permanent side effects enjoy resolution of her axillary and sis and management. CMAJ. 2005;172(1):69-75. 7. Weber A, Heger A, Sinkgraven R, et al. Psychoso- exists following ETS. The most fre- hand sweating. V.H. noticed compen- cial aspects of patients with focal hyperhidrosis: quent is compensatory satory sweating on her back in climate marked reduction of social phobia, anxiety and depression and increased quality of life after treat- hyperhidrosis, which occurs on the over 85°F (29 °C), which ment with A. Br J Dermatol. trunk and legs in up to 86% of pa- she rated as mild and not bothersome. 2005;152(2):342-345. tients.8 Horner’s syndrome, which At 2-year follow-up, V.H.reported 8. Connoly M, de Berker D. Management of primary hyperhidrosis. Am J Clin Dermatol. 2003:4(10): results in permanent miosis and ptosis complete resolution of her underarm 681-689. of the affected eye, has been reported and hand sweating. She experienced in 1% to 2% of patients treated with mild compensatory hyperhidrosis in Katherine Kenny is chief of advanced practice nurs- ing, Department of Internal Medicine, at St. Joseph’s ETS.3 Other less common, but known the summer months, yet still rated Hospital and Medical Center, Phoenix, Ariz. www.tnpj.com The Nurse Practitioner • July 2009 11