II. Definitions
- Hyperhidrosis
- Excessive sweating beyond physiologic need for Thermoregulation
III. Epidemiology
- Prevalence: 1-3% of U.S.
- Genetic predisposition
- Both genders affected equally (women report more often)
IV. Pathophysiology
- Eccrine Sweat Glands
- Most concentrated on the palms, soles, axillae and face
- Innervation by postganglionic autonomic nerve fibers
- Neurotransmitter: Acetylcholine
- Cerebral cortex releases stimuli secondary to emotion or physiologic stress
- Hypothalamus is hypersensitive to these stimuli
- Hyperhidrosis results from increased sympathetic stimulation
- Results in Eccrine Gland (Sweat Gland) hypersecretion
- Eccrine Glands are normal, but they are hyperstimulated
V. Types
- Primary Hyperhidrosis (90%)
- Idiopathic, bilateral, symmetric focal excessive sweating (see symptoms below)
- Secondary Hyperhidrosis
- Generalized or focal sweating due to underlying cause (medical condition, medication)
- See Hyperhidrosis Causes and Medication Causes of Hyperhidrosis
VI. Symptoms: Primary Hyperhidrosis
- Excessive focal sweating
- Axilla (50% of cases)
- Palms and soles
- Face
- Less common: Scalp, inguinal
- Exacerbated by stress or anxiety
- Only occurs while awake
- Contrast with Night Sweats
VII. Labs
- No labs needed unless secondary Hyperhidrosis is suspected by history, exam or lack of diagnostic criteria below
VIII. Differential Diagnosis: Secondary Hyperhidrosis
IX. Diagnosis: Primary Hyperhidrosis
- Focal, visible, excessive sweating for longer than 6 months without secondary Hyperhidrosis cause AND
- At least 2 of the following criteria (using 4 criteria increases Test Specificity for primary Hyperhidrosis to 99%)
- Bilateral and symmetric sweating
- Daily activity Impairment
- Occurs at least once per week
- Onset at age <25 years old
- No occurrence during sleep
- Positive Family History
X. Grading: Hyperhidrosis Disease Severity Scale (HDSS)
- Grade 1
- Sweating not noticeable and does not interfere with daily activities
- Grade 2 (mild)
- Sweating is tolerable, but sometimes interferes with daily activities
- Grade 3 (severe)
- Sweating is barely tolerable and often interferes with daily activities
- Grade 4 (very severe)
- Sweating intolerable and always interferes with daily activities
XI. Management: Axillary Hyperhidrosis
- Step 1: Topical Aluminum Chloride 20-25% (Drysol)
- Step 2: Onabotulinum Toxin A (Botox Injection)
- May start at step 2 in severe cases (HDSS 3-4)
- Step 2 Alternative: QBrexza (moistened glycopyrronium disposable cloth)
- Expensive (nearly $600/month in 2019) and Anticholinergic adverse effects (see below)
- Step 3: Oral Anticholinergics (e.g. Glycopyrrolate or Oxybutynin)
- Step 4: Consider microwave therapy
- Step 5: Consider local surgery
- Step 6: Consider sympathetic denervation (endoscopic thoracic sympathectomy)
XII. Management: Craniofacial Hyperhidrosis
- Step 1: Topical Aluminum Chloride 20% (Drysol) or topical glycopyrrolate 2%
- Step 2: Oral Anticholinergics (e.g. Glycopyrrolate or Oxybutynin)
- Step 3: Onabotulinum Toxin A (Botox Injection)
- Step 4: Consider sympathetic denervation (endoscopic thoracic sympathectomy)
XIII. Management: Palmar Hyperhidrosis
- Step 1: Topical Aluminum Chloride 20% (Drysol)
- Step 2: Onabotulinum Toxin A (Botox Injection) or Iontophoresis
- May start at step 2 in severe cases (HDSS 3-4)
- Step 3: Oral Anticholinergics (e.g. Glycopyrrolate or Oxybutynin)
- Step 4: Consider sympathetic denervation (endoscopic thoracic sympathectomy)
XIV. Management: Plantar Hyperhidrosis
- Step 1: Topical Aluminum Chloride 20% (Drysol)
- Step 2: Onabotulinum Toxin A (Botox Injection) or Iontophoresis
- May start at step 2 in severe cases (HDSS 3-4)
- Step 3: Oral Anticholinergics (e.g. Glycopyrrolate or Oxybutynin)
XV. Management: Methods - Topical Preparations
-
Aluminum Chloride hexahydrate 20-25% (Drysol, Xerac)
- Obstruct Eccrine Gland pores
- Results in atrophy of Sweat Gland secretory cells
- OTC agents are less expensive and higher concentration than prescription preparations
- Other agents with lower efficacy
- Antiperspirants containing aluminum zirconium trichlorohydrate (OTC)
- Topical Anticholinergic Agents (e.g. topical glycopyrrolate 2%)
- Glycopyrronium (Qbrexza) 2.4% wiped across each axilla daily
- Very expensive ($580/30 wipes in 2019)
- Anticholinergic effects (Blurred Vision, Dry Mouth) and local irritation
- (2018) presc lett 25(11): 65-6
- Arnold (2019) Am Fam Physician 100(6):372-3 +PMID:31524358 [PubMed]
- Glycopyrronium (Qbrexza) 2.4% wiped across each axilla daily
- Zeasorb Powder (Miconazole)
- Numerous others are not recommended (Formaldehyde, Glutaraldehyde, Boric Acid, tannic acid)
- Bedtime technique: First-line, preferred option
- Apply topical (Drysol) nightly for 6-8 hours until decrease in HDSS score
- Patients sweat less at night when topicals are more effective at blocking Eccrine Glands
- May then gradually space to 2-3 times per week at bedtime
- Apply Occlusive Dressing over night
- Remove in the morning and wash off
- May apply Baking Soda to skin to reduce irritation (Drysol may form HCL when combined with water)
- Apply topical (Drysol) nightly for 6-8 hours until decrease in HDSS score
XVI. Management: Methods - Systemic Preparations
-
Anticholinergics (Not recommended for longterm use, Anticholinergic adverse effects)
- Glycopyrrolate (Robinul)
- Oxybutynin (Ditropan)
- Phenoxybenzamine (Dibenzyline), an Antihypertensive agent
- Medications to reduce anxiety (low efficacy)
- Serzone
- Imipramine
- Propranolol
- Benzodiazepines
- Not recommended due to dependency risk
XVII. Management: Methods - Procedural and Surgical Interventions (Refractory, severe cases)
-
Botulinum Toxin Type A (Botox) local intradermal injection
- Safe and effective
- Binds synaptic Proteins and blocks Acetylcholine release
- Expensive ($1500 for both hands repeated q6-9 months)
- Regional Anesthesia (Median and Ulnar Nerve Block)
- Preferred option for axillary Hyperhidrosis
- Minor Starch-Iodine Test identifies area of injection
- Serial intradermal injections (0.1 ml aliquot/cm)
- Each injection spaced 0.5 to 2 cm apart
- Anhidrosis at each site persists 4-13 months
- Adverse Effects
- Injection site pain and Ecchymosis
- Decreased grip strength (palmar injection)
- Frontalis Muscle Weakness (forehead injection)
- Tap water Iontophoresis
- Direct current used to pass water (or other ionized substance) through the skin
- Safe, effective and well tolerated since the 1950s
- May be performed at home
- Galvanic current 15-20 mA applied to intact skin
- Hands and feet submerged in a device tray containing tap water
- Current applied to each distal extremity
- Apply current for 30 minutes on 3 days per week until improvement, and then weekly
- Adjuncts (increase efficacy)
- Aluminum Chloride hexahydrate (Drysol)
- Baking Soda (1 tbs)
- Glycopyrrolate (Robinul) 1-2 tabs crushed
- Atropine (limit to 1 mg per 30 cc tap water)
- Adverse Effects (mild)
- Skin erythema
- Skin vesiculation
- Paresthesias
- Direct current used to pass water (or other ionized substance) through the skin
- Microwave therapy (axillary Hyperhidrosis)
- Microwave technology destroys Eccrine Glands via heat induced cellular thermolysis
- Handheld transducer applied in the area identified with the Minor Starch-Iodine Test
- Used in the axilla and performed under Local Anesthesia
- Hong (2012) Dermatol Surg 38(5): 728-35 [PubMed]
- Jacob (2013) Semin Cutan Med Surg 32(1): 2-8 [PubMed]
- Fractionated microneedle radiofrequency (axillary Hyperhidrosis)
- Radiofrequency applied via microneedles inserted 2-3 mm under the skin
- Fatemi (2015) Australas J Dermatol 56(4): 279-84 [PubMed]
- Abtahi-Naeini (2016) Indian J Dermatol 61(2): 234 [PubMed]
- Endoscopic sympathectomy
- Surgical destruction of sympathetic ganglia
- Palmar: third thoracic ganglia (T3)
- Plantar: Not done due to Sexual Dysfunction
- Improves with 50% of T4 sympathectomy
- Consider iotophoresis as alternative
- Indications
- Method of last resort for severe Hyperhidrosis
- Case refractory to other measures
- Highly effective for palmar Hyperhidrosis
- Relative contraindications
- Axillary Hyperhidrosis (T4) due to poor efficacy
- Face, scalp Hyperhidrosis (T2)
- Due to very high risk of compensatory sweating
- Adverse effects and complications
- Compensatory sweating
- Trunk, groin, thighs and popliteal fossa
- Severe in 50% if T2 sympathectomy
- Severe in 19% if only T3 sympathectomy
- Clip removal may alleviate symptoms
- Gustatory sweating
- Sweating at back of neck when eating spicy food
- May follow T2 sympathectomy
- Also seen with Diabetic Autonomic Neuropathy
- Injury to adjacent structures during surgery
- Compensatory sweating
- Surgical destruction of sympathetic ganglia
XVIII. Resources
- International Hyperhidrosis Society
XIX. References
- Rakel (2002) Family Practice, Saunders, p. 1003-4
- Ferri (2004) Clinical Advisor, p. 1069
- Hornberger (2004) J Am Acad Dermatol 51(2): 274-86 [PubMed]
- Linn (1998) Eur J Surg, Suppl 580:13 [PubMed]
- McConaghy (2018) Am Fam Physician 97(11): 729-34 [PubMed]
- Stolman (1998) Dermatol Clin 16:863-9 [PubMed]
- Thomas (2004) Am Fam Physician 69(5):1117-21 [PubMed]
- Wailing (2011) J Am Acad Dermatol 64(4): 690-5 [PubMed]