Primary focal hyperhidrosis affects 3% of the US population; about the same number as psoriasis. More than half of these patients have primary focal axillary hyperhidrosis: sweating that is beyond what is anticipated or necessary for thermoregulation. Most topical therapies are based on aluminum salts, which work by a chemical reaction that forms plugs in the eccrine sweat ducts. Topical anticholinergics may also be used. Instruction on proper methods and timing of antiperspirants enhances effect and may be effective alone or in combination with other treatments in patients with hyperhidrosis.
Key points
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When used correctly, topical treatments for primary focal hyperhidrosis can provide significant benefit and, with patient education on usage, skin irritation can be limited and tolerable.
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Topical agents are a useful adjunct to other treatments such as onabotulinumtoxinA.
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Antiperspirants are most effective when applied to thoroughly dried skin at night.
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Many insurance companies consider treatment of hyperhidrosis with iontophoresis or onabotulinumtoxinA medically necessary only when topical aluminum chloride or other extrastrength antiperspirants are ineffective or result in a severe rash.
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Knowledge of the appropriate use of topical treatments is important for patient care on multiple levels.
Primary hyperhidrosis
The Nature of the Problem
Hyperhidrosis, also known as excessive sweating, is a dermatologic disorder characterized by sweating that is beyond what is anticipated or necessary for thermoregulation in the person’s environment. Primary, or idiopathic, hyperhidrosis and secondary hyperhidrosis are the chief categories of the condition. Primary hyperhidrosis (hyperhidrosis that is not caused by another medical condition or as a side effect of medication) presents in approximately 3% of the population. The excessive sweating experienced by people with primary hyperhidrosis is most often manifested at a focal body region such as on the palms, on the soles of the feet, in the axillae, or (less frequently) in the craniofacial region. Patients with primary hyperhidrosis often experience focal excessive sweating at more than one of the body locations listed earlier.
Hyperhidrosis is of great concern to patients because of its physical, occupational, psychological, and social impacts on quality of life. For instance, patients with hyperhidrosis report physical discomfort caused by wet clothing and shoes. In addition, skin maceration from persistent wetness can lead to bacterial and fungal overgrowth. This overgrowth can then cause intertrigo in the axillae as well as bromhidrosis (foul-smelling sweat), pitted keratolysis (an infection of the plantar surface characterized by pits or craters), and gram-negative bacterial infection and macerative infection of the feet. From a practical and economic standpoint, excessive sweat can stain and eventually destroy clothing and shoes. Patients may need to spend thousands of dollars annually for dry-cleaning and clothing replacement.
Psychosocial ramifications can be severe because of patient’s embarrassment and the cultural stigma associated with sweating. Stereotypes regarding the causes of sweating (other than as a reaction to heat or exercise) may include nervousness, incompetence at a task, lack of cleanliness, or dishonesty. Day-to-day lives are also affected severely by excessive sweating; patients may find that their activities of daily living are negatively affected such that simple tasks become difficult, and household, educational, or job-related tools and documents may become damaged by wetness. Baseline evaluation of a series of patients treated for axillary hyperhidrosis found that 90% of the group reported an effect on their emotional status, and more than 70% had to change clothes 2 or more times per day. More than 50% of patients with axillary hyperhidrosis identified in a US national consumer survey reported feeling less confident, 38% said they became frustrated by some daily activities, 34% were unhappy, and 20% said they were depressed.
Palmar hyperhidrosis can interfere with activities of daily living as well as with occupational tasks. Having sweaty palms makes it difficult to grip tools, play musical instruments, and use electronic devices, and paper can be stained and ink smeared by dripping sweat. Patients experiencing palmar excessive sweating have reported difficulty writing or drawing, frequent electric shocks, and dropping glass objects. Occupational problems for those with axillary or generalized hyperhidrosis include needing to change clothes frequently and anxiety regarding presentations in front of audiences because of sweat-stained clothing and resultant embarrassment. In the US national consumer survey mentioned earlier, 13% of patients with axillary hyperhidrosis reported a related decrease in work time.
Primary hyperhidrosis
The Nature of the Problem
Hyperhidrosis, also known as excessive sweating, is a dermatologic disorder characterized by sweating that is beyond what is anticipated or necessary for thermoregulation in the person’s environment. Primary, or idiopathic, hyperhidrosis and secondary hyperhidrosis are the chief categories of the condition. Primary hyperhidrosis (hyperhidrosis that is not caused by another medical condition or as a side effect of medication) presents in approximately 3% of the population. The excessive sweating experienced by people with primary hyperhidrosis is most often manifested at a focal body region such as on the palms, on the soles of the feet, in the axillae, or (less frequently) in the craniofacial region. Patients with primary hyperhidrosis often experience focal excessive sweating at more than one of the body locations listed earlier.
Hyperhidrosis is of great concern to patients because of its physical, occupational, psychological, and social impacts on quality of life. For instance, patients with hyperhidrosis report physical discomfort caused by wet clothing and shoes. In addition, skin maceration from persistent wetness can lead to bacterial and fungal overgrowth. This overgrowth can then cause intertrigo in the axillae as well as bromhidrosis (foul-smelling sweat), pitted keratolysis (an infection of the plantar surface characterized by pits or craters), and gram-negative bacterial infection and macerative infection of the feet. From a practical and economic standpoint, excessive sweat can stain and eventually destroy clothing and shoes. Patients may need to spend thousands of dollars annually for dry-cleaning and clothing replacement.
Psychosocial ramifications can be severe because of patient’s embarrassment and the cultural stigma associated with sweating. Stereotypes regarding the causes of sweating (other than as a reaction to heat or exercise) may include nervousness, incompetence at a task, lack of cleanliness, or dishonesty. Day-to-day lives are also affected severely by excessive sweating; patients may find that their activities of daily living are negatively affected such that simple tasks become difficult, and household, educational, or job-related tools and documents may become damaged by wetness. Baseline evaluation of a series of patients treated for axillary hyperhidrosis found that 90% of the group reported an effect on their emotional status, and more than 70% had to change clothes 2 or more times per day. More than 50% of patients with axillary hyperhidrosis identified in a US national consumer survey reported feeling less confident, 38% said they became frustrated by some daily activities, 34% were unhappy, and 20% said they were depressed.
Palmar hyperhidrosis can interfere with activities of daily living as well as with occupational tasks. Having sweaty palms makes it difficult to grip tools, play musical instruments, and use electronic devices, and paper can be stained and ink smeared by dripping sweat. Patients experiencing palmar excessive sweating have reported difficulty writing or drawing, frequent electric shocks, and dropping glass objects. Occupational problems for those with axillary or generalized hyperhidrosis include needing to change clothes frequently and anxiety regarding presentations in front of audiences because of sweat-stained clothing and resultant embarrassment. In the US national consumer survey mentioned earlier, 13% of patients with axillary hyperhidrosis reported a related decrease in work time.
Patient evaluation overview
The first step when evaluating a patient presenting with hyperhidrosis is a detailed clinical history with a focus on features of primary hyperhidrosis in order to support the diagnosis of primary focal hyperhidrosis ( Box 1 ). It is also critical to know the patient’s medical and surgical history as well as any medications, supplements, or complementary therapies that have been used. Review of systems should focus on the endocrine and neurologic systems. Physical examination includes an inspection for signs of excess sweating and/or related skin breakdown but such symptoms may not reliably be present. Laboratory testing is usually not required. The Hyperhidrosis Disease Severity Scale (HDSS) is a quick diagnostic tool providing insight into the impact of hyperhidrosis on the patient’s life ( Box 2 ). The results can be used to tailor treatment and for insurance reimbursement or coverage documentation purposes.
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Excessive sweating occurring in at least 1 of the following sites: axillae, palms, soles, or craniofacial region
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At least 6 months’ duration
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Without apparent secondary causes (eg, medications, endocrine disease, neurologic disease)
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Including 2 or more of the following characteristics:
Bilateral and approximately symmetric
Age of onset less than 25 years
Frequency of episodes at least once per week
Positive family history
Cessation of excessive sweating on sleep
Impairment of daily activities
Related posts:
Incidence and Prevalence of Hyperhidrosis
Impact of Hyperhidrosis on Quality of Life and its Assessment
Special Considerations for Children with Hyperhidrosis
Botulinum Toxin for Hyperhidrosis of Areas Other than the Axillae and Palms/Soles
Oral Medications
Local Procedural Approaches for Axillary Hyperhidrosis
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