Excessive sweating: causes and what to do about it

MODERN

MEDICINE

Excessive sweating: causes

and w hat to do about it

FRANK ISAACS, MB BS(Hons), FACD

Hyperhidrosis can be defined as an increase above normal sweat production. It occurs when sweat­ ing is clinically noticeable under conditions where it would not nor­ mally be expected or is excessive in response to heat or emotional stimuli. In most patients hyper­ hidrosis is a source of embarrass­ ment and can be a severe social problem. In some patients it can be an accessory factor in the pathogenesis of certain cutaneous disorders; in other cases it may be a sign of underlying disease.

W hat influences sw eating?

When talking about hyperhidrosis it is important to understand the pathophysiology. The sweat glands are innervated by the sympathetic nervous system. The box on this page describes the neural pathway involved. The sympathetic control of sweat glands is influenced by three main types of stimuli:

• thermal — in which the whole body sweats (ie generalized hyper­ hidrosis), but mainly the upper trunk and face are involved; the thermal stimuli are controlled by the heat-regulating centre in the hypothalamus

Dr Isaacs is a visiting medical officer at St Vincent's, St George and Sydney Hospitals, and is in general dermatology practice in Bondi Junction, NSW, Australia. This article was specially written for

M o d e r n M e d ic in e .

• gustatory — in which the sweat­ ing is on the lips, forehead and nose in response to hot, spicy foods • mental — in which there is some general body sweating, but mainly the palms and soles and/or axillae are involved.

As well as sympathetic neural control, local factors can be impor­ tant in influencing the amount and quality of sweat. These include local temperature, hormones, circu­ latory changes, axon and spinal- reflexes, and increased sweat gland numbers (sweat gland naevus).

It is clear that factors influenc­ ing various parts of the neural pathway may cause hyperhidrosis. Things that influence the hypo­ thalamus would cause a gener­ alised hyperhidrosis, whereas agents affecting a specific sympa­ thetic nerve would cause a local­ ized type of hyperhidrosis. The importance of differentiating local­ ized from generalized hyperhidro­ sis, both from the aetiological and therapeutic viewpoint, is obvious. Table 1 lists causes of hyperhidro­ sis categorized by which part of the neural pathway is thought to be responsible, and Table 2 lists non-neural causes.

Causes and clinical features Generalized hyperhidrosis

The causes of generalized hyper­ hidrosis include:

• disorders of the central nervous system, most often with irritative lesions of the hypothalamus

• administration of cholinergic agents or inhibitors of acetyl­ cholinesterase (eg neostigmine) • thyrotoxicosis — there may be generalized sweating and/or increased sweating of the palms and soles due to increased sympa­ thetic activity

• defervescence from fevers from almost any cause — some instabil­ ity of the sweat-regulating centres is caused by many febrile condi­ tions, so that sweating may occur at times when there is no fever • many chronic diseases associated with sweating episodes especially at night (eg tuberculosis, lymphomas, brucellosis); these are thought to be due to alterations in hypothalamic activity — thermoregulatory sweat­ ing unlike emotional sweating is usually worse during sleep

• sweating associated with cold vasoconstricted skin occurring with hypoglycaemia, the dumping syndrome, alcohol and drug with­ drawal, shock and syncopal states, and intense pain — sympathetic discharge probably accounts for this phenomenon

• other endocrine and metabolic disorders, including carcinoid syn­ drome, acromegaly, diabetes, hyperpituitarism, gout, obesity, tumours, menopausal states and phaeochromocytoma

• familial dysautonomia (Riley- Day syndrome).

Localized hyperhidrosis

Localized hyperhidrosis may be primary or secondary.

Primary localized hyperhidrosis

Primary localized hyperhidrosis involves the palms, soles and axil­ lae. It ceases during sleep and increases with emotion (mental sweating). Thermal stimuli may aggravate. The diagnosis is made

62 MODERN MEDICINE OF SOUTH AFRICA / JUNE 2000

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E xcessive sw eatin g ■ The sympathetic control o f sweat

continued

I

main types o f stimuli: thermal,

| gustatory and mental.

TABLE 1

Neural causes of hyperhidrosis

Cortical Cardiovascular Emotional Shock Palmoplantar keratodermas Heart failure Pachyonychia congenita Vasomotor

Nail-patella syndrome Raynaud's phenomenon or disease Familial dysautonomia Erythrocyanosis

Hypothalam ic

Cold injury

Symmetrical lividity of palms and soles Thermoregulatory Rheumatoid arthritis

Exercise Causalgia

Drugs Shoulder-hand syndrome Antipyretics Neurological

Emetics Tumours or local disease Insulin Familial dysautonomia Meperidine Parkinsonism

Intection Postencephalitic Metabolic Medullary

Hyperpituitarism Physiological gustatory sweating Hyperthyroidism Auriculotemporal syndrome Diabetes mellitus Syringomyelia, encephalitis Obesity After thoracic sympathetic section Menopause or injury

Pregnancy Granulosis rubra nasi

Gout Spinal

Hypoglycaemia Spinal injury (transection) Alcoholism Syringornelia

Debility Tabes dorsalis Toxic Axon reflex

Chronic arsenic intoxication Drugs (acetylcholine, nicotine) Drug addiction Perllesional

mainly by exclusion. This is by far the most common form of hyperhidrosis that would present to doctors.

• Hyperhidrosis of the palms and

soles. This is sometimes associated

with hyperhidrosis of the axillae. This type of hyperhidrosis is not in response to heat and is noted by the patient to be increased under conditions of mental stress. Most commonly this causes social embarrassment and soiling of clothes, and occasionally may interfere with occupations in which instruments and tools are handled. It affects both sexes and often begins in childhood or puber­ ty. There may be a family history. It tends to be very persistent, but may improve after 25 years of age. Plantar involvement is more com­ mon in young men.

Hyperhidrosis of the palms and soles can aggravate certain skin conditions including pompholyx, pitted keratolysis and tinea and predispose the patient to allergic sensation of the skin. Localized hyperhidrosis of the palms and soles may also be seen with vari­ ous forms of keratoderma of the palms and soles. A form of hyper­ hidrosis of the feet associated with vasomotor changes causing the sodden skin to be cold and cyanotic is known as symmetrical lividity.

• Hyperhidrosis o f the axillae. Axillary sweating responds to both heat or emotional stimuli or the combination of both. It is thus more troublesome in the summer. It is also a cause of major embar­ rassment and leads to secondary skin dermatoses. The onset is usually at 15 to 18 years of age (invariably postpubertal). It is not related to functional or organic disease.

Secondary localized hyperhidrosis

Secondary localized hyperhidrosis is frequently symmetrical and seg­ mental. It may be caused by dys­ function of the central or peripher­ al nervous system. While it may be a presenting symptom, it is rare for it to occur in the absence of other neurological disturbance.

Central nervous system dysfunc­ tion. CNS abnormalities include

encephalitis, hypothalamic lesions, intermedullary glioma, syringo­ myelia and anxiety.

Peripheral nervous system dys­ function. Peripheral nervous dys­

functions include diabetes, ther­ mal trauma (frostbite) and mechanical nerve injury (eg infil­ tration by a tumour or pressure from an ectopic structure such as a cervical rib). Tumours arising from the nerves themselves may also cause dysfunction.

• Gustatory secondary hyperhi­

drosis. This is mainly seen after

damage to sympathetic nerves around the head and neck. In

this situation the regenerating nerves make abnormal connec­ tions. The commonest site is the distribution of the auriculotem­ poral nerve after parotid injury, abscess or surgery (Von Frey's syndrome), where reflex arcs nor­ mally causing salivary gland secretion cause sweating.

• Compensatory hyperhidrosis. Localized hyperhidrosis can also be seen in compensatory hyper­ hidrosis, where some of the sweat glands are no longer functioning causing compensation hyperhidro­ sis in other areas; examples occur after some cases of sympathecto­ my and in miliaria.

64 MODERN MEDICINE OF SOUTH AFRICA / JUNE 2000

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Figure 1. Commercially available iontophoresis equipment. P hotograph reproduced courtesy of W a y n e Electronics, Somersby.

T re a tm e n t off hyperhidrosis

This section deals with the treatment of primary localized hyperhidrosis. Treatment of secondary hyperhidrosis (local or generalized) is treatment of the underlying disorder.

Explanation and reassurance

Explanation with reassurance is an important part of management. It should be stressed that many patients improve with time. Treat any underlying problems such as emotional and anxiety states, hyperthyroidism and diabetes.

Topical agents

Topical anticholinergics have not proved to be reli­ able. One per cent formalin soaks for soles may be helpful for some patients.

Aluminium chloride

Aluminium chloride hexahydrate in anhydrous alco­ hol should be used in the axillae at night before going to bed; they must be dry when it is applied. The axil­ lae are then washed in the morning. Most patients find the axillae are better after a week or so and then continue application on a less regular basis. If control is not achieved, plastic occlusion can be used in an attempt to increase efficacy.

In severe cases taking an oral anticholinergic 45 minutes before applying aluminium chloride for the first two to three nights may help allow retention of enough aluminium chloride to be effective. The main problem is irritation and use of a mild steroid cream may be necessary in the morning.

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Excessive sweating

■

Unlike emotional sweating,

continued.

■

thermoregulatory sweating is

usually worse during sleep.

TABLE 2

N o iw ieu ral causes

of hyperhidrosis

Organoid and sudonparous naevi

Maffucci's syndrom e {dyschondroplasia with haemanglomatosis)

Arteriovenous fistula

Klippel-Trenaunay syndrome Glomus tumours

Blue rubber bleb naevus syndrome Cold erythema

* Neural mechanisms participate tn these forms ol sweating, but It is the vascular or glandular abnormality that permits the local sweat glands to respond selectively

The same treatment can be used on the palms and soles.

Iontophoresis

Iontophoresis is a process where a small electric current is passed through the skin via immersing the affected part in a water bath (Figure 1). Anticholinergic agents can be added to the water bath, but it seems to work well without these and just plain tap water or salt water can be used. Treatment has to be done on a regular basis.

Iontophoresis is available through the physiotherapy departments of many larger hospitals, but because regular treatment is needed many patients choose to purchase their own equipment.

Botulinum toxin injection

Intracutaneous botulinum toxin injection is a new therapy which appears to be effective. A recent study showed no clinical hyperhidrosis in eight of 11 patients in a follow-up period of 12 to 20 weeks. Both axillary and palmoplantar areas can be treated (Figures 2 and 3).

Other treatment

Medications

Oral anticholinergic drugs are not used much because of

shown up by the Minor Figure 2b. No visible sweating after treatment with botu­

linum toxin injection.

Figure 3a. P alm ar hyperhidrosis revealed by iodine Figure 3b. The sweating is reduced after botulinum toxin

starch test. injection.

Figures 2 and 3 reproduced from Naumann M, et aJ. Arch Dermatol 1998; 134 (March): 301-304; copyright 1998, American Medical Association. Figure 2a. Axillary hyperhidrosis

iodine starch test.

66 MODERN MEDICINE OF SOUTH AFRICA / JUNE 2000

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T h e C o r n e r s t o n e

s

How bad does chemotherapy

make

you

_{feel, doctor?}

You may be shocked to know th a t only 50% o f South African cancer patients are ever referred fo r specialist o n co lo g ist opinion.

C ould this be because many a doctor, encountering advanced cancer

in a p a tie n t who thus, empirically, seems b e yon d help, shrinks from

causing fu rth e r suffering? C ould it be that, in th a t doctor's

experience, the outcom e o f chem otherapy in all b u t the m ost robust, o r lucky, seldom war­

ranted its ravages on a patient's quality o f life? It m ust often

have appeared kinder to advise one's p a tie n t to g o

hom e, set th e ir affairs in order, and live o u t w hat tim e was left, however short, with d ig n ity Fortunately, m odern referral decisions are less o f a dilem m a than ever before. Studies show th a t Gemzar, despite b e in g very well tolerated, easy to adm inister and low in side effects, slows disease progression and significantly extends survival time.

0)

c

So even when there's n o t much to be done, there is still this you can do: refer cancer patients to an o n colo g ist fo r the benefits o f Gemzar therapy.

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G E I^ Z A R

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Excessive sweating

■

Explanation with reassurance

continued

_{is an important part}

of management. Many

patients improve with time.

P ra ctic e points

• Hyperhidrosis is a real problem and a source of embarrassment for many patients.

• Most cases will be localized to the palms, soles and axillae and have no underlying cause, but It is worth doing thyroid function tests even in these patients.

• It ts important to distinguish between a localized and a generalized hyper­ hidrosis, both to seek out the cause and to determine the appropriate treatment.

• Look for aggravating factors (eg anxiety states).

•Thermoregulatory sweating, unlike emotional sweating, is usually worse during sleep.

• Explanation with reassurance Is an important part of management. Many patients with primary localized hyperhidrosis Improve with time.

• Most patients can be treated with aluminium chloride hexahydrate solution or iontophoresis.

•Treatm ent with intracutaneous botulinum injections shows some promise. • Sympathectomy should be reserved for severe cases of palmer and axillary

hyperhidrosis.

side-effects such as dry mouth, blurred vision, glaucoma, urinary retention and heat stroke. Beta- blockers may occasionally help. Tranquillizers are not suitable for long-term treatment.

Psychotherapy

Psychotherapy may help some patients, but primary hyper­ hidrosis is usually aggravated rather than caused by stress. It may be worth trying in very anx­ ious patients. Biofeedback tech­

niques may be helpful in some patients.

Surgery

Sweat gland removal

For the axillae, removal of the sweat glands can be undertaken. One way of doing this is by exci­ sion of the axillary vault, but this procedure does cause marked scar­ ring. Liposuction of the axillae to remove the sweat glands has also been used and would seem to be a reasonable alternative.

Sympathectomy

Sympathectomy is usually effec­ tive, but is associated with a num­ ber of problems including surgical complications, reinnervation, excessively dry palms and soles, and compensatory hyperhidrosis on other areas. It should be reserved for severe cases not amenable to other treatment. Newer techniques using endoscop­ ic approaches may be safer.

Conclusion

In conclusion, hyperhidrosis is a real problem for many patients. Most cases will be localized to the palms, soles and axillae and have no underlying cause, but it is worth doing thyroid function tests even in these patients. Most patients can be treated with alu­ minium chloride hexahydrate solu­ tion or iontophoresis. These simple treatments can be organized and managed in general practice. More stubborn cases are best referred.

References

1. Fitzpatrick TB, Eisen AZ, Wolff K, et al. Dermatology in general medicine. 2nd ed. New York: McGraw Hill, 1979.

2. Rook A, Wilkinson DS, Ebling FJ. Textbook of dermatology, 3rd ed. Oxford: Blackwell Scientific, 1979.

3. Moschella SI, Hurley HJ. Dermatology. 3rd ed. Phila­ delphia: Saunders, 1992.

4. McCoy B. Apical pulmonary adenocarcinoma with contralater­ al hyperhidrosis. Arch Dermatol 1981; 117:659-661.

5. Naumann M, Hofman U, Bergmann I, et al. Focal hyper­ hidrosis: effective treatment with intracutaneous botulinum toxin. Arch Dermatol 1998; 134:301-304.

6. Duller P, Gentry WD. Use of biofeedback in treating chronic hyperhidrosis: a preliminary report. Br J Dermatol 1980; 103: 143-146.

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