The Psychosocial Impact of Hyperhidrosis

Hyperhidrosis

Sweating is vital for thermal regulation and the natural way for the human body to cool itself. It also has a role in excretion and defense against microbes. Hyperhidrosis is a chronic autonomic disorder characterized by excessive sweating that is above the physiological needs of the body. This condition can lead to social anxiety that impacts one’s professional lifestyle and their mental health. Additionally, the constant moisture on the skin can lead to skin maceration which can increase the risk of skin conditions like athletes' foot or bacterial infections.

Hyperhidrosis affects approximately 4.3% of the United States population, with the majority of cases affecting the axillae. One third of patients report that the condition is intolerable and two thirds of patients report a family history. Primary hyperhidrosis is the result of an autosomal genetic mutation and usually affects those of ages 18-39 years old. Women are more likely to report symptoms to their doctor although prevalence among the sexes is about equal.

The axillae contains three types of sweat glands: eccrine, apocrine, and apoeccrine. Eccrine glands are located throughout the body. They gain function soon after birth and are innervated by cholinergic and sympathetic postganglionic unmyelinated C fibers under the control of the hypothalamus with acetylcholine as the primary neurotransmitter. Apocrine glands are located in specific areas of the body like the axillae and pubic area. They are innervated by sympathetic postganglionic sympathetic nerves with norepinephrine as the primary neurotransmitter. The sweat glands in the axillae are activated by emotional and thermal stimuli. Norepinephrine regulates both glands in emotional sweating. The cause of primary hyperhidrosis is not fully understood, but thought to be an increased sympathetic stimulation of eccrine sweat glands and abnormal control of emotional sweating. As sweating is increased, the enzyme that breaks down acetylcholine, acetylcholinesterase, is inhibited causing the lack of control.

Severity of hyperhidrosis can be measured using The Hyperhidrosis Disease Severity Scale (HDSS) which measures the frequency and tolerability of sweating. Treatment recommendations for all primary focal hyperhidrosis is a topical antiperspirant, aluminum chloride 20%. Aluminum chloride salts obstruct eccrine glands, destroy secretory epithelial cells, and plug the lumen. For craniofacial hyperhidrosis topical 2% glycopyrrolate can be used. One of the most studied treatments is botulinum toxin. This can be used in the axillae, soles of feet, face, and the palms. It works by blocking acetylcholine at the neuromuscular synapse. Other treatments include the use of devices. Microwave thermolysis is a new treatment used that destroys the eccrine sweat glands. Iontophoresis is another treatment that can be used for soles and palms. An electric current is applied and passes water through the skin. The exact mechanism of its effect is unknown but could be due to a decrease in pH, sympathetic nerve stimulation blockage, blockage of sweat secretion, and flow by a hyperkeratotic plug (Arora, et al.). There are several other emerging treatments for this condition.

Hyperhidrosis impacts peoples lives more than one may expect. Patients may experience anxiety or embarrassment when in social situations due to sweat showing on their clothes. They may have to avoid wearing certain colors or avoid certain foods that may make them sweat. Studies have shown an increased prevalence in anxiety and depression in those with hyperhidrosis compared to those without. An international study showed the prevalence of anxiety and depression was 21.3% and 27.2% respectively for patients with hyperhidrosis and 7.5% and 9.7% for those without (Lenefsky & Rice). This is a condition many people suffer with that can lead to several other conditions if left untreated. It is important for healthcare workers to provide a safe environment for patients to feel comfortable expressing their conditions.

Resources:

Arora, G., Kassir, M., Patil, A., Sadeghi, P., Gold, M. H., Adatto, M., Grabbe, S., & Goldust, M. (2022). Treatment of Axillary hyperhidrosis. Journal of cosmetic dermatology, 21(1), 62–70. https://doi.org/10.1111/jocd.14378

Lenefsky, M., & Rice, Z. P. (2018). Hyperhidrosis and its impact on those living with it. The American journal of managed care, 24(23 Suppl), S491–S495.

McConaghy, J. R., & Fosselman, D. (2018). Hyperhidrosis: Management Options. American family physician, 97(11), 729–734.

Hyperhidrosis

Sweating is an important function of the human body, helping to regulate body temperature, respond to emotional stress, and helping metabolism. There are 2 types of sweat glands in the human body: eccrine and apocrine glands. Eccrine glands are the most abundant, present throughout the body and are involved in temperature regulation. These glands release odorless fluid and electrolytes. Apocrine glands are found in the axillae, pubic area, and ear canal. They release sweat plus proteins and other chemicals like pheromones and steroids. This fluid from apocrine glands has a distinct odor due to bacteria-producing urea. Both the central nervous system and the autonomic nervous system are involved in regulating sweat secretion. Acetylcholine regulates thermal sweating and catecholamines like noradrenaline regulate emotional or stress-induced sweating. The autonomic nervous system can adjust the amount of sweating based on the environment, emotion or metabolism when functioning properly.

Hyperhidrosis is a condition in which patients sweat excessively, more than what is physiologically necessary. This condition affects approximately 2% of people in the United States. There are two types of hyperhidrosis: primary and secondary. Primary hyperhidrosis is idiopathic and bilaterally symmetric, affecting the axillae, palms, soles, or face. Secondary hyperhidrosis can be focal or generalized and is caused by a medical condition or medication use. In primary hyperhidrosis, the sympathetic stimulation of the eccrine glands leads to the increased sweating.

Hyperhidrosis affects patients’ quality of life by negatively impacting their self-esteem, relationships, productivity and emotional well-being.

Topical 20% aluminum chloride hexahydrate is the first-line treatment option for primary focal hyperhidrosis regardless of severity of the condition. It should be applied nightly to the affected areas for 6-8 hours and once improvement is seen, the patient can decrease to once or twice weekly, or as needed. Aluminum chloride hexahydrate works by obstructing the eccrine sweat glands and destroying the secretory cells. Adverse effects associated with this treatment include burning sensation, pruritus and skin irritation. If these skin irritations occur patients can opt for an over-the-counter antiperspirant containing aluminum zirconium trichlorohydrate which can decrease excessive sweating without as much irritation as the prescription product.

For facial hyperhidrosis, topical; 2% glycopyrrolate is used as first-line treatment. It is applied once every 2-3 days and has a low side effect profile with mild skin irritation as the main complaint.

For hyperhidrosis affecting the palms and soles, iontophoresis can be used as first or second-line treatment. This treatment involves passing an ionized substance like water through the skin by the application of electrical current. This treatment can be done at home for usually 3 days weekly until effects are observed and then decreased to once weekly as maintenance therapy. Adverse effects include erythema and tingling but are mild.

Botulinum toxin injection is another treatment option with consistent efficacy when used in the axillae and palms. The botulinum toxins bind to synaptic proteins and block the release of acetylcholine that activates the eccrine sweat glands. The toxin is administered intradermally in the affected area. The Minor starch-iodine test is used before injection to identify the exact areas where the sweat is most prominent. Treatment results last for 6-9 months. Adverse effects like injection site pain and decreased grip strength when injected into the palms have been reported.

Resources:

Lenefsky M, Rice Z. Hyperhidrosis and its impact on those living with it. AJMC. https://www.ajmc.com/view/hyperhidrosis-and-its-impact--on-those-living-with-it. Published December 19, 2018. Accessed March 25, 2022.

McConaghy JR, Fosselman D. Hyperhidrosis: Management options. American Family Physician. https://www.aafp.org/afp/2018/0601/p729.html. Published June 1, 2018. Accessed March 25, 2022.

Hyperhidrosis

Sweating is vital for the wellbeing of humans. It assists in thermoregulation, fluid/electrolyte balance and skin hydration. We have three types of sweat glands, eccrine, apocrine, and apoeccrine glands. The eccrine glands are responsible for regulating our body’s temperature; the evaporation from eccrine sweat results in a cooling effect. Eccrine glands are present substantially in the palms and soles and to a lesser extent the axillae. Our sweat secretion is modulated by our central and autonomic nervous system. The 2 main neurotransmitters involved are acetylcholine and catecholamines, such as noradrenaline. Acetylcholine regulates thermal sweating where heat stimuli causes sweating of the face, chest and back. Noradrenaline manages emotional or stress-induced sweating, causing sweating of the palms and soles. Thermal and emotional sweating are controlled by different parts of the brain. Thermal sweating is controlled by the hypothalamus while emotional sweating is regulated by the cerebral cortex.

Hyperhidrosis is the condition of excessive sweating beyond what is physiologically necessary. It can be classified as primary or secondary, based on the cause of sweating. The exact mechanism of primary hyperhidrosis is unknown but it is presumed to be an exaggerated response to sweating. It is not caused by external stimuli, body temperature, or disease. Symptoms are localized to the palms, soles, and axillae and generally develop in childhood or adolescence and persist for life. The diagnosis criteria consist of focal, visible excessive sweating for at least six months without an observable cause. Secondary hyperhidrosis can be due to medications, conditions and endocrine disturbances. The onset is usually after 25 years of age and presents as more generalized than focal.

Hyperhidrosis can have a negative impact on one’s quality of life. Patients suffering with axillary symptoms have reported staining of their clothes. Some have a fear of shaking other people’s hands due to their palmar hyperhidrosis. Patients sometimes have to take multiple daily showers, change clothes throughout the day, and have difficulty with simple tasks such as opening doors. All of this can lead to feelings of depression and anxiety which is why it is important we recognize their challenges and provide patients the care they need.

They are various types of treatment to combat hyperhidrosis. First line treatment for axillary hyperhidrosis include antiperspirants because they are highly accessible, inexpensive, and well-tolerated. Antiperspirants found in over the counter usually contain aluminum which physically blocks the opening of sweat gland ducts. However, there are also prescription strengths such as 20% aluminum chloride hexahydrate or 6.25% aluminum chloride hexahydrate for those who require it. Second-line therapy is botulinum toxin injections or microwave thermolysis. Botulin toxin injections have shown to improve axillary hyperhidrosis but can be painful and costly. Microwave energy is used to destroy the eccrine glands responsible for hyperhidrosis in the axilla. Systemic anticholinergics agents like oral glycopyrrolate can also be utilized but their adverse effects make it not a popular choice. Treatments for palmar and plantar hyperhidrosis are similar but iontophoresis has shown to be very effective. It uses electrical currents to temporarily block sweat glands. As healthcare providers, it is essential we validate our patients concerns and personalize their treatment in order to improve health outcomes.

References:

Lenefsky, Mary and Rice, Zakiya. “Hyperhidrosis and Its Impact on Those Living with It.” AJMC, Dec. 2018.

Smith, Christopher, and David Pariser. “Primary Focal Hyperhidrosis.” UpToDate, Jan. 2020.

Hyperhidrosis is a disorder of excessive sweating due to over-stimulation of cholinergic (nerve cells where acetylcholine (Ach) acts like the primary neurotransmitter) receptors on eccrine glands, which are the major sweat glands of the human body. This disorder manages to unfortunately be three disabilities all in one- a social, emotional and occupational disability which affects close to 3 % of the U.S. population. There are two different types of sweating that exist- thermoregulatory and emotional sweating. These two types of sweating are regulated by different centers in our body- thermoregulatory sweating is regulated primarily by the hypothalamus, which is the region of the forebrain below the thalamus and coordinates the autonomic system which has unconscious (involuntary) control over the body. Emotional sweating is regulated primarily by the limbic system, the part of our brain which is involved in regulating both the human body’s emotional and behavioral responses. The etiology of hyperhidrosis can also be categorized in two different ways. The first way is unknown albeit it’s thought to involve genetics and possibly deemed to be hereditary. The second way is much easier to identify as it can be easily associated with causative agents such as medications such as insulin, antipsychotics, and selective serotonin reuptake inhibitors (SSRIs). The cause for the second possible way can also be due to a patient’s past medical history (PMH) including his or her disease states/conditions (systemic disorders), including hyperthyroidism, Parkinson’s Disease, and diabetes mellitus.

The pathophysiology of excessive sweating is hyperactivity of the parasympathetic nervous system (our body’s “rest and digest” system) which causes an excess in the release of acetylcholine from the nerve endings. Acetylcholine (Ach) will then innervate the epidermal eccrine sweat glands as a physiologic response to our body’s core body temperature control, particularly in times of physical or psychological stress. In hyperhidrosis, it is postulated that the negative feedback ( a reaction that causes a decrease in function) mechanism to the hypothalamus may be impaired which then causes the body to sweat a lot more than what is needed to cool down the body's temperature.

Depending on the localization of hyperhidrosis, there are different types of treatment options. Local treatments include- aluminum chloride (AlCl) 15% to 25% concentration or antiperspirants, tap water iontophoresis for palmar/plantar sweating, and injections of botulinum toxin. AlCl works by reacting with proteins in the sweat duct and then subsequently forming a mechanical obstacle which prevents sweating. AlCl solutions should be applied on completely dry skin once a week or more, preferably when going to bed in order for it to work overnight. Iontophoresis is a type of electrical stimulation where the ions produced can physically block the sweat ducts in the stratum corneum, the outermost layer of the skin. Botulinum toxins are injected intradermally and inhibits the release of acetylcholine from the sudomotor synapses (anything that stimulates the sweat glands). Botox is considered to be the first-line therapy in treating compensatory hyperhidrosis, a common post-surgical complication of sympathetic surgery such as endoscopic thoracic sympathectomy (ETS) which is a type of surgery to treat hyperhidrosis.

References-

Schlereth, T, Dieterich, M, et al. Hyperhidrosis- Causes and Treatment of Enhanced Sweating. Dtsch Arztebl Int. 2009 Jan; 106(3): 32–37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695293/

Rystedt, A, Brismar, K, et al. Hyperhidrosis- an unknown widespread “silent disorder.” Journal of Neurology & Neuromedicine. https://www.jneurology.com/articles/hyperhidrosis--an-unknown-widespread-silent-disorder.html

Brackenrich, J, Fagg, C. Hyperhidrosis. Statpearls. https://www.ncbi.nlm.nih.gov/books/NBK459227/

Excessive sweating is a medical condition known as Hyperhidrosis. Sweating is an important function of the body because it cools the body which prevents the body from overheating. Sweating in a person with hyperhidrosis occurs even the body does not need to be cooled down. Common areas in which people sweat when they have hyperhidrosis are from the palms, feet, underarms, or head. Hyperhidrosis is not the same as sweating after a workout or on a really summery day. It presents in different ways such as: visible sweating when not exerting or overworking yourself, sweating that interferes with day-to-day activities such as havening difficulty opening a doorknob, skin that turns soft and white similar to what happens when having your hands in the water for too long, and lastly skin infections. A person suffering with hyperhidrosis might experience skin infections frequently. These skin infections can include athlete’s foot and jock itch since those infections occur from moist being trapped in the skin.

Hyperhidrosis is not a contagious medical condition but it may be brought on due to another medical condition that a person has such as diabetes, a tumor, or even an injury that causes trauma to the body. The condition is caused due to the nerves being excited or overacting.

There are two different types of hyperhidrosis: primal focal and secondary hyperhidrosis. Primary focal hyperhidrosis usually occurs at a young age and it is not caused by another condition. A person with primary focal hyperhidrosis may experience sweating in one or more parts of the body, both side of the body, after waking up, and at least once a week. As opposed to Primary focal hyperhidrosis, secondary hyperhidrosis occurs due to an underlying cause such as another medical condition. A person with secondary hyperhidrosis might experience sweating throughout the entire body as well as sweating during sleep. It might seem humiliating in a public setting and decrease from a person’s quality of life when living with hyperhidrosis.

There are a few different treatment options that can be used for hyperhidrosis. Antiperspirants such as deodorant can be used as first-line treatment. It is affordable and helps your body to reduce the amount of sweat produced. Iontophoresis is another treatment option that may be used on the hands or feet. It is a machine that uses electric current to slow down the sweat glands temporarily. It is usually a 20 to 40 minutes treatment session and most patients require 6 to 10 treatments in order to shut down the sweat glands. Botulinum toxin injections are another form of treatment primarily to treat sweating in areas of the underarms. This is FDA approved treatment that temporarily blocks the chemical in the body from stimulating the sweat glands.

Another FDA approved treatment is the used of prescription cloth wipes which contain an ingredient called glypyrronium tosylate which can reduce underarm sweating. The brand name of this treatment is Qbrexza and it can be used in patients as young as 9 years old. It is a topical that is applied once daily. Many people might only need one cloth for both underarms that lasts them the whole day. Qbrexza is in a medication class called anticholinergics. Anticholinergics might cause side effects of experiencing dry mouth, dry skin, and other effects therefore when using Qbrexza, one must be careful with the use of other medications that are anticholinergics as well.

Anticholinergic medications are also available to be taken by mouth that are off-label use for the treatment of hyperhidrosis. The oral medications include oxybutynin, glycopyrrolate, and others. There are other treatment options as well such as surgery and a new treatment approved by the FDA which destroys the sweat glands. Treatment options and effectiveness are different and are individualized based on the patient. It is important to speak with a dermatologist for the best treatment possible.

“Hyperhidrosis: Overview.” American Academy of Dermatology, www.aad.org/public/diseases/a-z/hyperhidrosis-overview.

“Oral Medication.” The Hyperhidrosis Center at Thoracic Group, www.sweathelpnj.com/treatments/oral-medications/.

Qbrexza. Package Insert. Dermira, Inc; 2018