20 Dermatology Hyperhidrosis Hyperhidrosis is a condition characterised by abnormally increased sweating, in excess of that required for regulation of body temperature. Hyperhidrosis can either be generalised or localised to specifc parts of the body, such as hands, feet and axillae. Hyperhidrosis can be divided into primary or idiopathic, and a secondary type. Te primary type usually starts during adolescence or even earlier, while secondary hyperhidrosis can start at any point in life. Te latter form may be due to a disorder of the thyroid or pituitary gland, diabetes mellitus, tumours, gout, menopause, or certain medications. Tis article highlights the clinical features and the treatment options for this condition. Nabil Aly, Consultant Physician, University Hospital Aintree, Liverpool email [email protected] Epidemiology Hyperhidrosis is sweating in axillae; localised hyperhidrosis, excess of that required for and generalised hyperhidrosis.1,2 normal thermoregulation. It is a Localised hyperhidrosis, unlike People of all ages can be afected condition that usually begins in generalised hyperhidrosis, by hyperhidrosis. Primary either childhood or adolescence usually begins in childhood or hyperhidrosis affects men and can affect any site on the adolescence. Localised unilateral and women equally, and most body. However, the sites most or segmental hyperhidrosis is commonly occurs among people commonly afected are the palms, rare and of unknown origin. aged 25–64 years. Some may soles, and axillae. Excessive The condition usually presents have been affected since early sweating may be primary on the forearm or forehead in childhood, and about 30–50% (idiopathic) or secondary to otherwise healthy individuals, have another family member medication use, certain diseases, without evidence of the typical afflicted, implying a genetic metabolic disorders, or febrile triggering factors found in predisposition.5 Localised illnesses. Hyperhidrosis often essential hyperhidrosis. Unilateral hyperhidrosis, unlike generalised causes great emotional distress hyperhidrosis with accompanying hyperhidrosis, usually begins in and occupational disability contra-lateral anhidrosis is also childhood or adolescence. In a for the patient, regardless of rare.3 Palmar hyperhidrosis is a study of 850 patients with palmar, the form and the extent of the benign functional disorder that axillary, or facial hyperhidrosis, problem. Hyperhidrosis is is a psychological and social 62% of patients reported that difcult to treat efectively. With handicap. Harlequin syndrome sweating began since before the newer treatment modalities is characterised by unilateral they could remember; 33% now available, the patient has hyperhidrosis and flushing, since puberty; and 5% during numerous options and is ofered predominantly induced by heat adulthood.6 In a cross-sectional a better prognosis. or exercise.4 The sympathetic primary care study among 795 defcits are usually limited to the older patients (older than 64 face.4 Night sweats among older years), 10% reported being Types people could be related to certain bothered by night sweats, 9% systemic conditions and clinical by day sweats, and 8% by hot Hyperhidrosis exists in three forms: assessment is always required flushes.7 All three symptoms emotionally induced hyperhidrosis, to rule out the presence of these were associated with reduced which affects palms, soles, and causes (Box 1). quality of life.7 GM | Midlife and Beyond | June 2012 www.gerimed.co.uk Dermatology 21 less numerous and are found in Box 1: Common causes of night sweats among older patients the axilla and genital regions. Te apoeccrine glands are found only in the adult axilla. Te eccrine Te condition Clinical features type is the one mainly involved Menopause Women would also experience in hyperhidrosis. Hyperhidrosis hot fushes is usually stimulated by emotion Pulmonary tuberculosis (TB) Usually associated with fatigue and stress, so it does not occur and anorexia during sleep or sedation. While However, atypical presentation is normal sweating is controlled not uncommon primarily by thermoregulation Diabetes mellitus Tis type of hyperhidrosis could and, thus, occurs independently be a manifestation of autonomic of level of consciousness. The dysfunction primary defect in patients with hyperhidrosis may be Medications* Several medications may induce hypothalamic hypersensitivity excessive sweating at night to emotional stimuli from the In general, the drugs listed cerebral cortex.8 Generalised below can be associated with hyperhidrosis may be the hyperhidrosis consequence of autonomic Lymphoma Nights sweats are a symptom of dysregulation, or it may develop certain types of Hodgkin’s disease secondary to a metabolic found in older patients disorder, febrile illness, or Parkinson’s disease Te condition can be associated malignancy. In its localised form, with localised or generalised hyperhidrosis may result from a hyperhidrosis disruption followed by abnormal Mental disorder/stress Anxiety and depression may cause regeneration of sympathetic night sweats nerves or a localised abnormality in the number or distribution of the eccrine glands, or it may be * These include: Calcitonin, fentanyl, acyclovir, ceftriaxone, levothyroxine, associated with other (usually levodopa and carbidopa, quetiapine, amlodipine, omeprazole, insulin, vascular) abnormalities. When medroxyprogesterone, testosterone, prednisolone and tamoxifen. caused by stress, hyperhidrosis may be generalised or limited to the palms, soles, and forehead.8 Pathophysiology sweat production are mainly controlled by the cerebral cortex, Te pathophysiology underlying anterior hypothalamus and the Aetiology hyperhidrosis is complex and sympathetic nervous system. In not well understood. Tere are addition, there are three types of Hyperhidrosis can be idiopathic two distinct types of sweating: sweat glands: eccrine, apocrine or sometimes secondary to other thermal sweating, which tends and apoeccrine. The eccrine diseases, metabolic disorders, to occur on the trunk and is type is the most numerous type, febrile illnesses, or medication controlled by the hypothalamus predominantly occurring on the use. Use of medications may via the thermo-sensitive preoptic soles of the feet, palms, axilla and afect one or more components sweat centre, and emotional face, and this type is innervated by of human thermoregulation sweating, which is predominately the sympathetic nervous system, and induce hyperhidrosis. on the palms and soles and with acetylcholine as the principle Hyperhidrosis beginning later is regulated by the cerebral neurotransmitter.8 Apocrine in life should prompt a search cortex. Thermoregulation and glands are androgen-dependent, for secondary causes such www.gerimed.co.uk June 2012 | Midlife and Beyond | GM 22 Dermatology as systemic diseases, adverse Box 2: Secondary causes of hyperhidrosis effects of medication use, or metabolic disorders. Secondary Generalised hyperhidrosis causes may include endocrine (an area >100 square cm) diseases such as diabetes • Afecting almost any skin area mellitus, hyperthyroidism, and • Starts at older age hyperpituitarism.8 In one series, • Symmetry is not very distinctive one third of cases were neurologic • Could be related to secondary causes, including medications in origin, including peripheral and systemic disorders nerve injury, Parkinson disease, reflex sympathetic dystrophy, Localised hyperhidrosis spinal injury, and Arnold-Chiari malformation.9 Other secondary (an area <100 square cm) causes to be considered may • Afects axillae more than hands include pheochromocytoma, • Starts at early age (<25) and improve later (>50) respiratory disease, and • Usually bilaterally symmetrical psychiatric disease (Box 2). • Tends to cease during sleep Asymmetric hyperhidrosis may • Mainly related to autonomic dysfunction. suggest neurologic disease.9 1. Neurologic or neoplastic diseases Primary hyperhidrosis usually 2. Spontaneous periodic hypothermia and hyperhidrosis starts during adolescence or even 3. Metabolic disorders or processes: thyrotoxicosis, diabetes before and seems to be inherited mellitus, hypoglycemia, gout, pheochromocytoma, as an autosomal dominant genetic menopause trait. Primary hyperhidrosis 4. Febrile illnesses must be distinguished from 5. Medications: propranolol, physostigmine, pilocarpine, secondary hyperhidrosis, tricyclic antidepressants, and serotonin reuptake inhibitors. which can start at any point 6. Chronic alcoholism in life. Primary hyperhidrosis 7. Hodgkin disease or tuberculosis (causing nocturnal can be differentiated from hyperhidrosis) secondary type by certain clinical 1) Gustatory stimuli: criteria (Box 3). These criteria • Seen in Frey syndrome, encephalitis, syringomyelia, diabetic discriminate well between the two neuropathies, herpes zoster parotitis, and parotid abscess types (sensitivity: 0.99; specifcity: 2) Eccrine nevus & Blue rubber-bleb nevus 0.82; positive predictive value: 3) Eccrine angiomatous hamartoma* 0.99; negative predictive value: 4) Glomus tumor 0.852) and may facilitate 5) POEMS syndrome: Peripheral neuropathy, organomegaly, optimal clinical management.10 endocrinopathy, monoclonal plasma-proliferative disorder, and Essential hyperhidrosis is a skin changes. dermatologic and neurologic 6) Burning feet syndrome disorder characterised by 7) Pachydermoperiostosis excessive sweating of the eccrine 8) Pre-tibial myxoedema sweat glands.11 It is a disorder of the eccrine sweat glands and is