Hyperhidrosis

Primary hyperhidrosis is the condition characterized by abnormally increased sweating, in excess of that required for regulation of body temperature.

Signs and symptoms
Hyperhidrosis can either be generalized or localized to specific parts of the body. Hands, feet, axillae, and the groin area are among the most active regions of perspiration due to the relatively high concentration of sweat glands; however, any part of the body may be affected. Primary hyperhidrosis is found to start during adolescence or even before and seems to be inherited as an autosomal dominant genetic trait.

Primary hyperhidrosis must be distinguished from secondary hyperhidrosis, which can start at any point in life. The latter form may be due to a disorder of the thyroid or pituitary gland, diabetes mellitus, tumors, gout, menopause, certain drugs, or mercury poisoning. Such secondary forms may have more serious consequences than hyperhidrosis.

Affected areas

 * Palmar: excessive sweating of the hands.
 * Axillary: excessive sweating of the armpits.
 * Plantar: excessive sweating of the feet.
 * Facial: excessive sweating of the face. (i.e. not emotional or thermal related blushing)
 * Cranial: excessive sweating of the head, especially noted around the hairline.
 * General: Overall excessive sweating.

Cause
It is not known what causes primary hyperhidrosis. Depending on how severe their condition is, some affected patients experience a reduction in their quality of life. Sufferers may feel a loss of control, because perspiration takes place independent of temperature and emotional state.

However, anxiety can exacerbate the situation for many sufferers. A common complaint of patients is that they get nervous because they sweat, then sweat more because they are nervous. Other factors can play a role; certain foods & drinks, nicotine, caffeine, and smells can trigger a response (see also diaphoresis).

Treatment
Hyperhidrosis can often be very effectively managed.

Medications

 * Aluminium chloride (hexahydrate) solution: While aluminium chloride is used in regular antiperspirants, hyperhidrosis sufferers need a much higher concentration to effectively treat the symptoms of the condition. A 15% aluminium chloride solution or higher usually takes about a week of nightly use to stop the sweating and one or two nightly applications per week to maintain the results.  An aluminium chloride solution can be very effective, however a minority of patients cannot tolerate the irritation that it can cause.  Also, the solution is usually not effective for palmar (hand) and plantar (foot) hyperhidrosis - for which iontophoresis (see below) may yield better results in some circumstances. For the severe cases of palmar and plantar hyperhidrosis there is a low level of success using conservative measures such as Aluminium chloride antiperspirants.


 * Botulinum toxin type A (including Botox ): Injections of the botulinum toxin are used to disable the sweat glands. The effects can last from 4-9 months depending on the site of injections. With proper anesthesia the hand and foot injections are almost painless. The procedure when used for underarm sweating has been approved by the U.S. Food and Drug Administration (FDA).


 * Oral medication: There are several oral drugs available to treat the condition with varying degrees of success.
 * A class of anticholinergic drugs is available that has been shown to reduce hyperhidrosis. Ditropan  (generic name: oxybutynin) is one that has shown promise.  However, most people cannot tolerate the side effects associated with the drug, which include drowsiness, visual symptoms and dryness in the mouth and in other mucus membranes.  A time release version of the drug is also available, called Ditropan XL , with purportedly reduced effectiveness.  Robinul  (generic name: glycopyrrolate) is another drug used on an off-label basis.  The drug seems to be almost as effective as oxybutynin, with similar side-effects such as a dry mouth or dry throat often leading to pain in these areas.  Other less effective anticholinergic agents that have been tried include propantheline bromide (Probanthine ) and benztropine (Cogentin ).
 * A different class of drugs known as beta-blockers has also been tried, but does not seem to be very effective.
 * Antidepressants and anxiolytics (anti-anxiety medications) are more archaic, related to the former, false belief that Primary Hyperhidrosis was related to an anxious personality style.

Surgical procedures

 * Surgery (Endoscopic thoracic sympathectomy or ETS): Select sympathetic nerves or nerve ganglia in the chest are either excised (cut out), burned, or clamped (theoretically allowing for the reversal of the procedure). The procedure causes relief of excessive hand sweating in about 85-95%.  Major drawbacks related to compensatory sweating are seen in 20-80%. In a series in India, the incidence was found to be 62%.Other side effects include Horner's Syndrome (about 1%), gustatory sweating (less than 25%) and on occasion very dry hands (sandpaper hands). Most people find the compensatory sweating to be tolerable while 1-4% find it worse than the initial condition.  Some patients have also been shown to experience a cardiac sympathetic denervation, which results in a 10% lowered heartbeat during both rest and exercise. ETS was thought to be helpful in treating axillary hyperhidrosis, facial blushing and facial sweating. Yet, palmar hyperhidrosis patients have the best results and some surgeons only offer ETS for this group. Statistics have shown that when treated for facial blushing and/or excessive facial sweating, the failure rate of ETS for those two clinical presentations is higher and patients are more prone to side effects.


 * Surgery (Lumbar Sympathectomy): Lumbar sympathectomy is a relatively new procedure aimed at those patients for whom endoscopic thoracic sympathectomy has not relieved excessive plantar (foot) sweating. With this procedure the sympathetic chain in the lumbar region is clipped or divided in order to relieve the severe or excessive foot sweating. The success rate is about 90% and the operation should be carried out only if patients first have tried other conservative measures. More recently leading surgeons who perform endoscopic thoracic sympathectomy are doing it only for excessive hand sweating (palmar hyperhidrosis).


 * Surgery (Sweat gland suction): In a new and novel technique adapted and modified from liposuction, approximately 30% of the sweat glands are removed with a proportionate reduction in sweat.


 * Percutaneous Sympathectomy: a minimally invasive procedure in which the nerve is blocked by an injection of phenol.

Other

 * Iontophoresis: This method was originally described in the 1950s, and its exact mode of action remains elusive to date. The affected area is placed in a device that has two pails of water with a conductor in each one. The hand or foot acts like a conductor between the positively- and negatively-charged pails.  As the low current passes through the area, the minerals in the water clog the sweat glands, limiting the amount of sweat released.  Common brands of tap water iontophoresis devices are the Drionic, Idrostar and MD-1A (RA Fischer).  Some people have seen great results while others see no effect.  However, since the device can be painful to some (pain is usually limited to small wounds and over time the body adjusts to the procedure) and the process is time-consuming, a lack of results in some people may be the result of not using the device correctly.  The device is usually used for the hands and feet, but there has been a device created for the axillae (armpit) area and for the stump region of amputees.


 * Weight loss


 * Relaxation and meditation


 * Hypnosis: Hypnosis has been used with some success in improving the process of administering injections for the treatment of hyperhidrosis.


 * Talc/Baby Powder: One temporary treatment is talc or baby powder because the powder will absorb the sweat; however, the powder may become a messy white coating on the place of application.


 * Shoe Inserts: "Absorbent insoles" decrease the sweat in shoes.

Prognosis and impact
Excessive sweating of the hands interferes with many routine activities, such as securely grasping objects. Some hyperhidrosis sufferers avoid situations where they will come into physical contact with others, such as greeting a person with a handshake. Hiding embarrassing sweat spots under the armpits limits the sufferers arm movements and pose. In severe cases, shirts must be changed several times during the day. Additionally, anxiety caused by self-consciousness to the sweating may aggravate the sweating. Excessive sweating of the feet makes it harder for patients to wear slide-on or open-toe shoes, as the feet slide around in the shoe because of sweat.

Some careers present challenges for hyperhidrosis sufferers. For example, careers which require the deft use of a knife may not be safely performed by people with excessive sweating of the hands. Employees, such as sales staff, who interact with many new people can be negatively affected by social rejection. The risk of dehydration can limit the ability of some sufferers to function in extremely hot (especially if also humid) conditions. Even the playing of musical instruments can be uncomfortable or difficult because of sweaty hands.

Since it is known that more than 50% of patients have a genetic history with excessive sweating leading doctors are hoping that one day genetic manipulation will offer the best source of treatment. It is still a distant possibility but with time and more research devoted to this problem a non-surgical solution can be found.

Epidemiology
Primary hyperhidrosis is estimated at around 3-4% of the population, afflicting men and women equally. It commonly has its onset in adolescence. About 3-40% have another family member afflicted, demonstrating a genetic transmission.