Badr Al Samaa, Barka, Sultanate of Oman, Oman
Received date: 29/08/2017; Accepted date: 08/11/2017; Published date: 16/11/2017
Copyright: © 2017 Raveendran AV. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Excessive sweating or hyperhidrosis is a rare clinical problem. Here we are presenting a case report of a man with excessive sweating.
Hyperhidrosis, Essential or primary, Palmar hyperhidrosis, Antiperspirants, Iontophoresis, Botulinum toxin
Excessive sweating also called hyperhidrosis can be due to various causes. Evaluation of hyperhidrosis depends upon the associated clinical features. Primary hyperhidrosis is a rare clinical condition.
A 30 year old male presented with excessive sweating of both hands and feet since last 10 years, which cause social embarrassment and difficulty to work resulting in anxiety (Figures 1 and 2). He is not having any significant history of weight loss, palpitation, heat intolerance, tremor, abnormal behaviour, seizure, loss of consciousness, headache, flashing episodes, neurological problems, diabetes or any malignancies. He is not taking any medicines. Clinical examination was normal except for presence of profuse seating of both hands and foot. Routine investigations and thyroid function test were within normal limit and we made a clinical diagnosis of essential or primary hyperhidrosis.
Figure 1: A 30 year old male presented with excessive sweating of both hands.
Figure 2: A 30 year old male presented with excessive sweating of both feet.
He was treated with topical Aluminium chloride, with partial improvement in his symptoms. Other treatment options like systemic anticholinergic, Botulinum toxin injection and various surgical methods were also discussed with him, but he was not willing for further treatment.
Excessive sweating or hyperhidrosis is a rare clinical problem and occurs only in 1% of the population, which can cause social embarrassment, lack of confidence, anxiety, difficult to work, social phobia and withdrawal leading to depression [1].
Hyperhidrosis can be physiological or pathological. Physiological causes includes hot climate, physical activity, anxiety, stress, severe pain, food intake, defervescence, pregnancy, obesity or after menopause. Pathological hyperhidrosis can be due to various causes including endocrine disorders (hyperthyroidism, pheochromocytoma, and hypoglycaemia), chronic infection (tuberculosis, malaria, brucellosis), neoplasm (carcinoid tumours, Hodgkin disease), neurological disorders (autonomic dysregulation, familial dysautonomia) and medication induced (Table 1) [2]. Hyperhidrosis can be emotionally induced, exertional or pyrexia induced. Emotionally induced or exertional hyperhidrosis is usually transient and associated with tachypneoa, tachycardia and fluctuation in blood pressure.
| Category | Drugs |
|---|---|
| Anti-viral | Acyclovir |
| Anti-hypertensive | Amlodipine, verapamil, lisinopril, nifedipine |
| Antibiotics | Ciprofloxacin, moxifloxacin, bacitracin |
| Anti-diabetic and hormones | Glipizide, insulin regular, levothyroxine, prednisolone |
| Anti- histamine | Loratadine |
| Analgesics/ anasthetic | Naproxen, indomethacin, mepivacaine, lidocaine and epinephrine, fentanyl, oxycodone, hydrocodone |
| Bronchodilators | Albuterol |
| CNS drugs | Citalopram, desipramine,nortriptyline, protriptyline, sertraline, buproprion, paroxetine, trazodone, zolpidem |
| Cholinergic | pilocarpine |
| Cardiac drugs | Digoxin |
| Proton pump inhibitors | Esomeprazole, omeprazole |
| PDE-5 inhibitors | Tadalafil, vardenafil |
| Statins | Atorvastatin |
| Supplements | trace metals, zinc supplements |
| Tryptans | Sumatriptan |
| Others | Nicotine |
Table 1: Drugs causing hyperhidrosis.
Hyperhidrosis can be focal (Localized) or generalized [2]. Focal hyperhidrosis is usually idiopathic and depending upon the site of involvement, it can be either under arms (axillary hyperhidrosis), hands (palmar hyperhidrosis), sole of the foot (planter hyperhidrosis) or face (Facial or cranial hyperhydrosis or Cranio facial). Focal hyperhidrosis can also be due to Freys syndrome or gustatory sweating, chorda tympani syndrome or eccrine angiomatoid nevus. Regional hyperhidrosis can be compensatory. Compensatory hyperhidrosis is a phenomenon associated with increased sweating in parts of the body unrelated to the location of treatment or in the case of surgery, unrelated to surgery or anatomy. Regional hyperhidrosis can be due to spinal cord lesions (tetraplegia and high level paraplegia, syringomyelia, focal brain lesions), trauma or reflex sympathetic dystrophy. Generalized hyperhidrosis is usually due to secondary causes.
When there is no obvious case for hyperhidrosis it is called primary or essential hyperhidrosis, which is idiopathic and begins from childhood or adolescence and persist throughout life.
Hyperhidrosis impact questionnaire (HIQ)/hyperhidrosis diseases severity scale helps to assess disease severity and its impact in day to day life [3].
In patients with primary focal hyperhidrosis positive family history is there for 55-65% of cases and is probably due to autosomal dominant inheritance [4].
Multiple site hyperhidrosis is common in patients with primary focal hyperhidrosis, palmo-plantar (28%) being most common, followed by axillary plus palmo-plantar (6%) and axillary plus palmar (2%).
In patients with hyperhidrosis, due to increased skin moisture, risk of cutaneous infections like verruca vulgarise, dermatophytosis, pitted keratolysis, etc., are more.
Patho-Physiology
There are 3 types of sweat glands in human body. They are:
• Eccrine glands: Eccrine glands involved in thermo regulation and secrete hypotonic solution with valuable amount of electrolyte. It is widely distributed.
• Apocrine glands: Apocrine glands secretion contains more fat, protein and salts. It is restricted to face and hands.
• Apoeccrine glands: Apoeccrine glands secretion also contains more fat, protein and salt. It is seen mainly in the mammary, axillary and genital areas.
Eccrine sweat glands are primarily seen in palm, sole and axilla, but widely distributed throughout body except external auditory canal, lips clitoris and labia minora. Eccrine sweat glands are primary involved in primary focal hyperhidrosis but apoeccrine glands also play a role in axillary hyperhidrois.
Higher concentrations of ecrine sweat producing glands are seen in the axilla, palms and soles, and to a less concentration in face and scalp. These sweat glands are innervated by sympathetic postganglionic unmyelinated class C nerves fibres, which have acetylcholine as primary neurotransmitter.
A central sudomotor efferent pathway starts from cerebral cortex to hypothalamus and to medulla which crosses to opposite side at modularly level to descend lateral horn of spinal cord to reach sympathetic ganglia and from there to sweat glands as postganglionic C fibres. Sweat glands in the palms and soles are activated by emotional stimuli and emotional sweating will not occur during sleep or sedation.
Thermal sweating is controlled by hypothalamic centre and emotional sweating is controlled by cerebral cortex. In patients with primary focal hyperhidrosis, the pathology is exaggerated central response to normal stress.
Primary hyperhidrosis is believed to be due to abnormal central control of emotional sweating and hence it affects the same body area involved in emotional sweating like palms, soles and axilla. As mentioned in the diagnostic criteria for primary hyperhidrosis, excessive sweating is absent during sleep.
Approach to hyperhidrosis
Hyperhidrosis is a clinical diagnosis, which can be confirmed by Iodine-starch reaction, which involve spraying iodinated starch powder on the affected area, which will change to black colour on exposure to sweat. This will help to map the areas involved. The diagnostic criterion for Primary hyperhidrosis is given in Table 2 [5].
In patients with hyperhidrosis ask for history of weight loss, palpitation, heat intolerance, tremor, abnormal behaviour, seizure, loss of consciousness, headache, flashing episodes, neurological problems, diabetes, intake of medicines, any malignancies or major illness in the past to rule out secondary cause of hyperhidrosis. Look for Tachycardia, hypertension, thyroid swelling, and tremor of hands, lymphadenopathy and focal neurological deficient to identity the cause of hyperhidrosis. Investigations can be planned as per clinical suspicion. High ESR may be an indicator of underlying chronic infections or serious malignancy. In a patient with hyperhidrosis without any obvious secondary cause, primary or essential hyperhidrosis is diagnosed.
Minor’s starch iodine test or quinizarin test is used to map areas of excessive sweating to assess the response to therapy.
Treatment
Localized hyperhidrosis like axiliary hyperhidrosis can be managed with antiperspirants containing aluminium chloride. In more severe hyperhidrosis aluminium chloride hex hydrate (20%) dissolved in anhydrous ethyl alcohol can be applied to dried skin every night and can be washed next day morning initially and then tapered to lowest minimum frequency depending upon the clinical response [6]. Systemic anticholinergic agents like glycopyrrolate; oxybutynin is useful in patients with localized and generalised hyperhidrosis (Table 3).
Iontophoresis is useful in patients with palmo-plantar hyperhidrosis. Iontophoresis is introduction of an ionized substance through intact skin by application of mild electric current carried through water. There are two theories about its mechanism of action. They are:
• Electrical gradient theory: Ionotophoresis disturb the electrical gradient in the sweat glands which is responsible for the normal movement of sweat along with sweat ducts [7].
• Plug theory: lonophoresis result in the formation of Schiff- positive, diastase-resistant material (plugs) in the lumen of eccrine sweat glands, resulting in obstruction of sweat glands [8].
Botulinum toxin injection is useful in patients with focal hyperhidrosis and the effect lasts for 4-12 months and may require multiple injections. Transient weakness of the small muscles of hand, which lasts for 2-3 weeks, can occur with botulinum toxin [9].
Clonidine is useful in hyperhidrosis secondary to menopause and tricyclic anti-depressant induced hyperhidrosis. Fludrocortisones acetate (0.3 mg daily) is useful for hyperhidrosis in quadriplegic with orthostatic hypotension. Psychotherapy is useful in patients with emotion induced hyperhidrosis.
In resistant cases, various surgical methods like excision of axillary tissue, axillary liposuction and thoracic sympathectomy are carried out.
Primary hyperhidrosis is a rare clinical problem, which is usually focal, most commonly involving palmo-plantar region, leading to social embarrassment, anxiety and social phobia. Local antiperspirants, systemic anticholinergics, Iontophoresis and Botulinum toxin injection are the medical treatment options available.
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