Hyperhidrosis

Introduction

Hyperhidrosis is a benign skin condition of overproduction of sweat beyond the required thermoregulatory response.

  • More than 90% of cases are primary, but secondary medical conditions or medications should be excluded.
  • About 65% of patients with focal hyperhidrosis have family history.



Symptoms

Primary hyperhidrosis is typically focal and symmetric and most frequently affecting the axillae, but may also affect the soles of the feet, palms of the hands or the face.

  • Most commonly starts between ages 14-25 years old.
  • In cases where onset is before puberty, it more often affects the hands and feet.
Secondary hyperhidrosis may be focal or generalized.
  • Caused by underlying medical condition or medication use (e.g. SSRI, SNRI, cholinergic agonists, selective oestrogen receptor modulators).



Management

Advise patients to avoid environmental situations (e.g. spicy foods, alcohol, stressful situations) and clothing (tight clothing, occlusive shoes) that makes them sweat, if possible.

For primary focal hyperhidrosis,

  • Topical antiperspirants are the preferred initial treatment because they are widely available, inexpensive and well tolerated therapies.
    • Offer topical aluminium chloride salts (6.25%-25%) for most cases.
    • Consider topical glycopyrrolate as an alternative.
  • For refractory or more severe symptoms, consider botulinum toxin type A intradermal injection.
    • Treatment can be painful and expensive.
    • Drying effect is not permanent, but may last 6-9 months and most patients need treatment 1-2 times per year.
    • Botulinum toxin A injections are contraindicated in patients with neuropathies or neuromuscular junction diseases and patients who are pregnant or breastfeeding.
  • If symptoms are not responsive to topical agents or botulinum toxin type A intradermal injection, consider oral anticholinergics (e.g. oxybutynin, glycopyrrolate)
    • Doses required to reduce sweating, however, often cause adverse effects including dry mouth, urinary retention, blurred vision, constipation or tachycardia.



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