Overview of Hyperhidrosis

Symptoms, causes, diagnosis, and treatment

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Hyperhidrosis is a term used to describe excessive sweating that affects the body’s natural temperature. It is not simply heavy sweating that occurs with strenuous activity. Rather, it is a clinical disorder in which profuse perspiration occurs either in response to an underlying disease or for no known reason at all.

Hyperhidrosis is not the same thing as excessive sweating during exercise or in response to hot or humid climates. It suggests an abnormal response under conditions for which sweating would not occur (or occur as dramatically) in most people.

Symptoms

Hyperhidrosis can be classified by the parts of the body affected as well as the underlying cause of the excessive sweating. The sweat glands, also known as sudoriferous or sudoriparous glands, are located throughout the human body, the number of which can vary from one person to the next.

The eccrine sweat glands are distributed over most of the body and function as the body’s primary cooling system. The apocrine sweat glands located primarily in the armpits and around the anus serve no regulatory purpose.

From the broadest perspective, hyperhidrosis can be described as being either primary focal hyperhidrosis or secondary hyperhidrosis.

Primary Focal Hyperhidrosis

Primary focal hyperhidrosis, also known as primary hyperhidrosis or essential hyperhidrosis, is characterized by localized sweating on specific parts of the body. The sweating is typically bilateral (occurring on both sides of the body) and most commonly affects the apocrine glands of the armpits, followed by the eccrine glands of feet, palm, scalp, and groin.

Primary hyperhidrosis is so-named because the sweating is the condition. While there may be triggers that set off an episode, the triggers are not considered unusual and will not cause symptoms in other people.

Around 3 percent of the population are affected by primary hyperhidrosis. The condition is equally common in men and women.

While primary hyperhidrosis is not considered dangerous, it can often be debilitating and severely impact a person’s quality of life. It is for this reason that the condition is often referred to as a “silent handicap.”

Primary hyperhidrosis may be further broken down by the part of the body affected. Among them:

  • Axillary hyperhidrosis is limited to the armpits.
  • Craniofacial hyperhidrosis involves the head and face.
  • Palmoplantar hyperhidrosis affects the hands (palmar) and/or feet (plantar).
  • Gustatory hyperhidrosis, also known as Frey’s syndrome, affects the scalp, face, neck, and/or chest immediately after eating certain foods.
  • Idiopathic unilateral circumscribed hyperhidrosis is a condition of unknown origin in which profuse sweating is localized to one side of the body.

Primary hyperhidrosis often begins in childhood, especially palmoplantar hyperhidrosis. While people with primary focal hyperhidrosis will typically experience episodes once or several times a week, they usually do not sweat excessively while sleeping.

Understanding Hyperhidrosis in Young Children

Secondary Hyperhidrosis

Secondary hyperhidrosis is the second form of hyperhidrosis characterized by the generalized sweating of the entire body.

Secondary hyperhidrosis is so-named because the sweating is the secondary consequence of an underlying cause, most often a disease, physiological disorder, or medication side effect.

As opposed to primary focal hyperhidrosis, secondary hyperhidrosis can occur at any age. It may also occur while sleeping in the form of night sweats.

Causes

The causes of hyperhidrosis are numerous. In some cases, the cause may never be found, particularly with primary hyperhidrosis. In others, the cause may be obvious and potentially treatable, as can happen with cases of secondary hyperhidrosis.

Primary Hyperhidrosis

While the exact cause of primary hyperhidrosis remains something of a mystery, it has been hypothesized that certain triggers can overexcite the sympathetic nervous system in some people. The sympathetic nervous system is part of the autonomic nervous system that regulates the body’s response to intense stimulus and triggers the so-called "fight-or-flight" response.

Anxiety, stress, and excitement are common triggers for primary hyperhidrosis, although the location and duration of the response can vary. "Flop sweat" is a colloquialism often ascribed to the sudden and profuse outbreak of sweat, most often in association with jitters and nerves.

Certain foods, drink, caffeine, and nicotine can also trigger sweating in a way that is anything but normal. While it is natural, for instance, to sweat when you eat especially hot or spicy food, people with gustatory hyperhidrosis may do so when they eat something cold. In some cases, even smelling or thinking of food can elicit a response.

Primary hyperhidrosis is also believed to have a genetic cause given that 30 percent to 50 percent of those affected will have a family history of the condition.

With that being said, the diversity of symptoms suggests that there may be a variety of genetic causes. In 2006, scientists with Saga University in Japan were able to approximate the location of a genetic anomaly on chromosome 14q11.2-q13, which they believe predisposes an individual to primary palmar hyperhidrosis.

At its very heart, primary hyperhidrosis represents a complex dysfunction of the autonomic nervous system and the endocrine system which receives the nerve signals and regulates perspiration. Any problem occurring along this route can potentially trigger the overproduction of sweat.

Secondary Hyperhidrosis

Secondary hyperhidrosis is sweating caused by a medical condition or is drug-induced. It is a symptom of a primary condition rather than the condition itself. The causes may be related to cancer, hormonal dysfunction, infections, medications, metabolic disorders, and systemic medical conditions.

Some of the more common medical conditions associated with secondary hyperhidrosis include:

Some of the medications known to cause secondary hyperhidrosis include:

  • Anticholinesterases used to treat Alzheimer’s disease
  • Antidepressants
  • Anxiolytic drugs used to treat anxiety
  • Asthma inhalers like albuterol
  • Celebrex (celecoxib) used to treat inflammation
  • Depo-Provera birth control pills
  • Insulin used to manage diabetes
  • Methadone used to treat heroin addiction
  • Migraine medications like Triptan (rizatriptan) and sumatriptan
  • Opioids like Vicodin (hydrocodone) and Oxycontin (oxycodone)
  • Salagen (pilocarpine) used to treat glaucoma
  • Propranol used to treat angina and hypertension
  • Testosterone
  • Thyroid-regulating drugs

Diagnosis

Hyperhidrosis is diagnosed based on the severity of perspiration in the absence of heat or excessive exercise. Moreover, episodes must occur at least once weekly. The first step in the diagnostic process is to differentiate primary focal hyperhidrosis from secondary hyperhidrosis. This can often be done with a physical exam and lab tests.

Physical Examination

There are several clues that can help differentiate the two conditions:

Primary Hyperhidrosis

  • Limited to one or several parts of the body

  • Usually manifests with symptoms before 25 and peaks by 35

  • Will rarely involve night sweats

  • Will often affect other family members

  • Will occur in the absence of any other symptoms

Secondary Hyperhidrosis

  • More generally widespread across the body

  • Risk increases with age

  • Will often involve night sweats

  • Less commonly affects other family members

  • Often occurs in tandem with other symptoms

The combination of medical history, family history, duration of symptoms, the age of onset, and absence or presence of an apparent cause are usually enough to make the differentiation.

Lab Tests

Based on the initial evaluation, your doctor may order tests to pinpoint the areas and severity of your condition. Called “sweat tests,” the procedures can help establish whether the cause is related to an autonomic or neurologic condition. They include:

  • Iodine-starch test: Involves the application of an iodine solution and starch powder to the skin. It is used to locate areas of profuse sweating and highlight the density of pore distribution.
  • Skin conductance: Involves the use of electrodes and electrical currents to detect changes in sweat gland activity.
  • Thermoregulatory sweat tests: Conducted in a sauna-like room during which you are sprinkled with powder to analyze how your body reacts to changes in temperature, humidity, and air flow.

Blood tests may also be ordered to confirm or exclude underlying causes. Based on your symptoms and risk factors, your doctor may want to test for low blood sugar (hypoglycemia), overactive thyroid function (hyperglycemia), or specific infections using blood antibody or antigen tests.

Treatment

The treatment of hyperhidrosis varies by the cause.

If hyperhidrosis is secondary to an underlying condition, the focus would be placed on treating the disorder rather than the sweating. In some cases, it may only require the resolution of a short-term febrile infection or the termination of a problematic drug. Other conditions may require chronic medications, surgery, or more extensive lifestyle changes.

Generally speaking, if the underlying condition is resolved or managed, the symptoms of hyperhidrosis will correct themselves.

However, if no clear cause is found, the treatment will be focused on controlling the sweating. A combination of treatments is often required. Even then, recurrence is common, and additional or repeated treatments may be needed.

Home Remedies

The easiest way to handle excessive sweating is with the daily use of an antiperspirant containing aluminum salts. The antiperspirant works by forming a plug in the pore of the sweat gland. Doing so sends signals to the brain to halt the production of sweat. These are easily found over-the-counter and in prescription formulations as well.

Don't confuse antiperspirants for deodorants which are used to conceal smells. While most antiperspirants are equally effective, unscented ones may be less irritating to people with sensitive skin or who are prone to contact dermatitis.

While people commonly use them on their underarms, the roll-ons and stick formulations can also be applied to the hairline, hands, groin, and feet. Always pre-test the antiperspirant on a patch of skin. Skin irritation and a burning sensation are common side effects. You will also need to wash regularly to prevent pore blockage.

Contrary to popular belief, shaving your armpits does not reduce the amount you sweat.

Medications

If over-the-counter antiperspirants fail to do the trick, your doctor may be able to prescribe you a number of stronger and potentially more effective medications. Among them:

  • Drysol and Xerac AC are prescription-strength antiperspirants that are applied at night and washed off in the morning. They are relatively strong and may require the short-term use of a hydrocortisone cream if skin irritation occurs.
  • Anticholinergic drugs, taken orally, are sometimes used off-label to treat hyperhidrosis. These include glycopyrrolate, oxybutynin, benztropine, and propantheline, which appear to block certain receptors responsible for sweating. Side effects may include dry mouth, dry eyes, constipation, blurred vision, heart palpitations, and difficulty breathing.
  • Qbrexza (glycopyrronium) cloth is an anticholinergic drug infused in a pre-moistened disposable towelette. Applied once-daily to the underarms only, it is the first-of-its-kind prescription medication approved for the treatment of primary axillary hyperhidrosis by the U.S. Food and Drug Administration (FDA). The side effects are similar to those seen with oral anticholinergics.

Procedures

A number of in-office procedures may be used to treat hyperhidrosis, either on their own or in combination with over-the-counter or prescription medications. Among them:

  • MiraDry was approved by the FDA in 2015 to treat primary axillary hyperhidrosis. It employs electromagnetic pulses to deactivate the sweat gland through thermolysis (decomposition by heat). The 20-minute to 30-minute procedure is performed in a doctor’s office with a local anesthetic. Several treatments may be needed to achieve effective and permanent sweat control. A mild pain reliever and an ice pack can help manage the pain in the day following the procedure.
  • Botulinum toxin (Botox) injections can block the nerves that cause sweating for anywhere from six to 12 months. While effective, the series of injections may be painful and may cause temporary muscle weakness. The treatment would need to be repeated once the effects wear off.
  • Iontophoresis involves the use of a medical device that passes a mild electrical current through water to stimulate tissues of the feet or hand. While the 15-minute to 40-minute procedure may provide relief of palmoplantar hyperhidrosis, the treatment needs to be performed on a regular maintenance schedule (usually once weekly). There are no significant side effects. Home iontophoresis units are also available for purchase.

    Surgery

    In severe cases, surgery may be considered in hyperhidrosis is severely impacting your quality of life and ability to function normally. They should only be considered if all other forms of conservative therapy have failed to provide relief. Options include:

    • Sweat gland removal involves either traditional surgery to remove subcutaneous tissues containing axillary sweat glands or a form of liposuction (called suction curettage) in which subcutaneous tissue and deeper dermal tissue are sucked out.
    • Sympathectomy is a type of nerve surgery in which a spinal nerve is removed to control the sweating in your hands. In some instances, the surgery may trigger irreversible compensatory sweating in which excessive sweating breaks out in other parts of the body. It is considered a last-resort option due to the risk of complications.
    • Sympathatomy is also used for palmar hyperhidrosis but involves the cutting, clamping, or burning of a spinal nerve to block the nerve signal. The procedure is considered less invasive than a sympathectomy, with a lower risk of compensatory sweating.

    Coping

    Whether you’re dealing with primary or secondary hyperhidrosis, there are things you can do.

    One of the best ways to avoid a sweating episode is to identify the triggers that set them off (such as caffeine or nicotine). If you are unsure of the cause, keep a "sweat diary" to record what you were doing when an episode occurred.

    In addition:

    • Avoid hot, humid weather whenever possible.
    • When outdoors or working out, keep your body temperature down by drinking cold water.
    • Wear loose-fitting cotton socks and clothing (even at the gym).
    • Avoid caffeine, alcohol, and spicy foods.
    • Apply antiperspirant to your feet and hands before bedtime or when preparing for a social situation.
    • Avoid shoes without fabric lining or buy absorbent insoles.
    • Let your athletic shoes dry out completely before putting them on. You can also drop them in the dryer if needed.
    • Bring an extra-large absorbent towel to workouts.
    • Shower daily, but avoid saunas, steam rooms, or hot showers that raise the body temperature.
    • Explore relaxation techniques and mind-body therapies like guided imagery, progressive muscle relaxation (PMR), and meditation to help to reduce the underlying stress that can trigger or exacerbate sweating episodes.

    It may surprise you to know that there are unofficial support groups for people with hyperhidrosis. You can find groups online on Facebook or reach out to the non-profit, Pennsylvania-based International Hyperhidrosis Society for advice and referrals.

    A Word From Verywell

    If you are suffering from excessive, uncontrollable sweating, it's important to remember that you aren't alone. There are treatments available that may at the very least minimize the occurrence of hyperhidrosis and lifestyle changes you can make to better cope.

    Start by speaking with your doctor to identify the underlying cause of your condition. A diagnosis and effective treatment is often a process of trial and error, so it’s important to remain patient and not give up out of frustration. 

    If hyperhidrosis is causing you extreme anxiety or you find yourself increasingly isolated from others, ask your doctor for a referral to a therapist who can help you better deal with the psychological and social stress. Even though hyperhidrosis is not life-threatening, it can be life-altering. Do yourself a favor and don’t ignore your condition.

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