Hyperhidrosis

Overview
Primary hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature. There is controversy regarding the definition of hyperhidrosis, because any sweat that drips off of the body is in excess of that required for thermoregulation. Almost all people will drip sweat off of the body during heavy exercise.

Classification of Sweating
There are four types of sweats:
 * 1) Diaphoresis: Diaphoresis is a cold sweat. Diaphoresis is excessive sweating commonly associated with shock and other medical emergency conditions. It is distinguished from hyperhidrosis by the "clammy" or "cold state" state of the patient.
 * 2) Primary Hyperhidrosis: Primary hyperhidrosis is a condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature. This is not a cold sweat.
 * 3) Secondary Hyperhidrosis: Secondary hyperhidrosis is a condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature that is secondary to an underlying pathologic process such as infections, disorders of the thyroid or pituitary gland, diabetes mellitus, tumors, gout, menopause, certain drugs, or mercury poisoning. This is not a cold sweat.
 * 4) Night sweats: Sleep hyperhidrosis, more commonly known as the night sweats, is the occurrence of excessive sweating (hyperhidrosis) during sleep. The sufferer may or may not also suffer from excessive perspiration while awake.

Presentation
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 interestingly, 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. For some, it can seem to come on unexpectedly. 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 just hyperhidrosis, making medical consultation advisable.

Incidence and prevalence
Primary hyperhidrosis is estimated at around 1% of the population, afflicting men and women equally. That number, however, does not reflect the true number of cases since the condition is not always diagnosed; most patients usually disregard the excessive sweating and it never occurs to them that they might have a medical condition. It commonly has its onset in adolescence.

Cause
It is not known what causes primary hyperhidrosis. One theory is that hyperhidrosis results from an overactive sympathetic nervous system, but this hyperactivity may in turn be caused by abnormal brain function.

Some patients afflicted with the condition experience a certain degree of reduction in their quality of life, depending on how severe their condition is. Sufferers feel at 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).

Differential Diagnosis of Diaphoresis (a "Cold Sweat" which is different from hyperhidrosis)

 * Alcohol withdrawal
 * Anxiety
 * Nightmare
 * Night terror
 * Panic attack
 * Shock
 * ST Elevation Myocardial Infarction
 * Trauma
 * Vagal episode

Complete Differential Diagnosis of Secondary Hyperhidrosis (Excess Sweating):
In alphabetical order.


 * Acromegaly
 * Acute hypertensive crisis
 * Acute rheumatic fever
 * Autonomic dystonia
 * Brucellosis
 * Carcinoid syndrome
 * Castration
 * Chronic infections
 * Collagen vascular disease
 * Diabetes Mellitus
 * Diabetic neuropathy
 * Drugs
 * Dumping syndrome
 * Encephalitis
 * Endocarditis lenta
 * Fever
 * Fructose intolerance
 * Glycogenoses I, III, VI
 * Heart attack
 * HIV infection
 * Hodgkin's Lymphoma
 * Hypernephroma
 * Hyperthyroidism
 * Hypoglycemia
 * Hypoglycemic shock
 * Hypogonadism
 * Insulinoma
 * Left heart failure
 * Malaria
 * Mastocytosis
 * Menopause
 * Mercury poisoning
 * Non-Hodgkin's lymphoma
 * Obesity
 * Parkinson's Disease
 * Phenylketonuria
 * Pheochromocytoma
 * Pneumonia
 * Polyneuropathy
 * Primary liver cell carcinoma
 * Pulmonary Embolism
 * Rheumatoid Arthritis
 * Rickets
 * Sarcomas
 * Serotonin syndrome
 * Shock
 * Syringomyelia
 * Tabes Dorsalis
 * Traumatic brain injury
 * Tuberculosis
 * Vagal episode
 * Viral infections
 * Withdrawal in drug addicts

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)
 * General: Overall excessive sweating.

Treatment
Hyperhidrosis can usually be very effectively controlled, but there is no known permanent cure because little is known about the cause behind excessive sweating.

Medications

 * Antiperspirants (Drysol) can be applied to the hands and armpits at night and then removed in the morning. These are usually tried first and may be effective in mild cases.


 * Aluminum chloride (hexahydrate) solution: Common brands of aluminum chloride solution (as antiperspirant) include, MegaDry® (which uses a non-irritating blend of aluminum chlorohydrate), B+Drier®, Odaban®, Sweat-Stop forte® and Driclor®.  While aluminum chloride is used in regular antiperspirants, hyperhidrosis sufferers need a much higher concentration to effectively treat the symptoms of the condition.  A 15% aluminum chloride solution or higher usually takes about a week of nightly use to stop the sweating, with one or two nightly applications per week to maintain the results.  An aluminum chloride solution can be very effective; some people, however, cannot tolerate the irritation that it can cause but these constitute a minority of all patients.  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.


 * Botulinum toxin type A (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), and now some insurance companies pay partially for the treatments.


 * Oral medication: There are several oral drugs available to treat the condition with varying degrees of success.
 * A class of anticholinergic drugs are available that have shown to reduce hyperhidrosis. Ditropan® (generic name: oxybutynin) is one that has been the most promising.  For some people, however, the drowsiness and dry-mouth associated with the drug cannot be tolerated.  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 nearly as effective.
 * Since the disorder is often caused by or exacerbated by high-anxiety, antidepressant drugs can help alleviate symptoms.

Non-medicinal

 * Surgery (Endoscopic thoracic sympathectomy or ETS): Select sympathetic nerves or nerve ganglia in the chest are either cut or burned (completely destroying their ability to transmit impulses), or clamped (theoretically allowing for the reversal of the procedure). The procedure often causes anhidrosis from the mid-chest upwards, a disturbing condition.  Major drawbacks to the procedure include thermo regulatory dysfunction (Goldstien, 2005), lowered fear and alertness and the overwhelming incidence of compensatory hyperhidrosis.  Some people find this sweating to be tolerable while others find the compensatory hyperhidrosis to be worse than the initial condition.  It has also been established that there is a low (less than 1%) chance of Horner's syndrome.  Other risks common to minimally-invasive chest surgery, though rare, do exist.  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 facial blushing and facial sweating. According to Dr. Reisfeld,the only indication for ETS at present is excessive and severe palmar hyperhidrosis (excessive hand sweating). 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 (Sweat gland suction): A new technique adapted and modified from liposuction. On an out-patient basis with only local anesthesia, the sweat glands are permanently removed in a gentle, non-aggressive manner. The sweat glands and armpits are first softened and anesthetized with a special solution. After a short period, the sweat glands can then be removed in a manner similar to liposuction. Only small incisions above and under the armpits are required to remove the sweat glands through quick suction. The entire minimally invasive operation takes between 60 and 90 minutes. Patients can go home directly after the procedure. Some can even return to work after leaving the practice, although taking the rest of the day off is recommended. Over 95% of patients report considerably less discomfort and permanent dryness.


 * 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 (it is important to note that pain is usually limited to small wounds and that over time the body adjusts to the procedure) and a great deal of time is required, no cessation of sweating in some people may be the result of not using the device as required.  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: Hyperhidrosis can be aggravated by obesity, so weight-loss can help. However, most people with hyperhidrosis do not sweat excessively due to obesity.
 * Relaxation and meditation: Relaxation techniques have been tried with limited success.
 * Hypnosis: Hypnosis has been used with limited success.
 * Percutaneous Sympathectomy: a minimally invasive procedure in which the sympathectomy nerve is blocked by an injection of phenol.
 * Talc/Baby Powder: One temporary treatment is talc or baby powder because the powder will absorb the sweat; however, after a while the powder may become a messy white coating on the place of application.


 * Acupuncture

Natural Remedies

 * Sage Herb: Sage Herb has also traditionally been used to treat excessive sweating in Germany as well as for night sweats caused by menopause or tuberculosis. It can be taken as a tea or in capsule form daily and can reduce sweating by 50% or more. The herb sage has also been found to boost memory and has many other benefits.

Social effects
Excessive sweating impedes the performance of many routine activities. Things like driving, taking tests and simply grasping objects are severely hampered by sweaty hands.

Some hyperhidrosis sufferers feel they have to avoid situations where they will come into physical contact with others. Interviews, a common source of anxiety for many people, are particularly harrowing for hyperhidrosis patients. Most often, it is the handshake before and after the interview that they will be stressing most about. 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 aggravates the sweating.

Compounding the problem is the cost of many treatments. Many people who suffer from this condition cannot afford procedures such as surgery or botox, therefore are left to deal with this problem with no solution.

Similarly, it can be increasingly difficult to participate in group athletic activities, such as team tennis, when the embarrassment of excessive perspiration can become so extreme that one becomes an object of ridicule. It becomes exceedingly difficult to maintain even the most peripheral friendships. Among those who have been publicly and privately ostracized as a result of their hyperhidrosis include   the nationally ranked USTA athlete, Barbara Zidek.

Effects on employment
Many careers present challenges for hyperhidrosis sufferers; cooks and chefs, doctors, and people working with computers can be affected by the social aspect of their condition. The risk of de-hydration can limit the ability of sufferers to function in extremely hot conditions without reasonable access to a source of hydration as well as cause a risk of mineral and salt imbalance from excessive sweating.