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Overview

This Guidelines summary provides information on the aetiology, history, clinical findings, types of condition, investigations, and management for patients presenting with hyperhidrosis (excessive sweating), including generalised, palmar and plantar, axillary, and craniofacial hyperhidrosis.

This is a summary of recommendations relevant to primary care health professionals. For further information, refer to the full guideline.

View this summary online at guidelines.co.uk/455981.article

Definition

  • Primary or focal hyperhidrosis, which presents without an associated condition, is a common disorder affecting approximately 1% of the population. It is an embarrassing and disabling condition, defined as sweating in excess of that required for normal temperature regulation
  • It generally presents in childhood, but it is not unusual for the sufferer to wait until adolescence before seeking medical help. Most present before the age of 25
  • Many sufferers are reluctant to seek medical help as they have often lived with their condition for many years and find it too embarrassing to discuss with their GP
  • There is a family history in about a third of cases and the disease follows a chronic course, ensuring that most people will need treatment on a continuous basis throughout their lives
  • Primary hyperhidrosis most commonly affects the palms, soles of the feet, and the axillae, but may affect any part of the body, and association with the face and head is not uncommon
  • Sufferers do not sweat excessively during sleep. If sweating is present at night, then consideration should be made for further investigation as this would almost certainly be due to a secondary factor.

Aetiology

  • Hyperhidrosis is linked to overactivity of the sympathetic nervous system. Specifically, it is the thoracic sympathetic ganglion chain, which runs along the vertebra of the spine, inside the chest cavity. This chain controls the apocrine and eccrine glands. The eccrine sweat glands are responsible for perspiration throughout the entire body and, when the chain is overactive, it causes excessive sweating at most times during the day. This in turn may cause considerable social, psychological, and occupational problems.

Factors that may modify primary hyperhidrosis

  • Hormonal factors—many females will find that their condition is either reduced or exacerbated during their menstrual cycle and when pregnant
  • Stress—this is a controversial issue as some patients are accused of ‘causing’ their hyperhidrosis by overreacting to their sweating. However, many dermatological conditions are exacerbated by stress, but this is not the cause of primary hyperhidrosis
  • Cosmetics—permanent or long-lasting cosmetic products often exacerbate hyperhidrosis of the face and high-factor sunscreens on other parts of the body.

Types of hyperhydrosis

  • Focal ‘typical’—palms, soles, axillae, and craniofacial
  • Focal ‘atypical’—asymmetric patches. May be due to a functional naevus
  • Generalised
  • Gustatory—induced by food or drink, and can be associated with diabetes. The Frey syndrome occurs in patients with gustatory sweating caused by nerve damage following facial trauma or parotid surgery.

Clinical findings

  • Bilateral excessive sweating most of the day; most commonly found on the palms, soles, axillae, or face
  • If the feet are affected there is an increased incidence of fungal infections due to excessive sweat being trapped inside shoes.

Investigations

  • Investigations are seldom, if at all, indicated for focal hyperhidrosis
  • Generalised hyperhidrosis in a well patient with a classical history of sweating starting in late childhood and improving in middle-age is seldom related to an underlying medical condition
  • If the history is less typical, for example, symptoms starting in a different age group, night sweats, or if the patient is unwell, there could be a secondary cause:
    • general medical conditions, especially Parkinson’s disease, diabetes mellitus, or thyroid disease
    • medications (new or recent withdrawal)—fluoxetine, opiates, oestrogens, and goserelin can cause sweating. Sildenafil and apomorphine can cause craniofacial hyperhidrosis
    • night sweats—could be due to lymphoma. Such a symptom warrants a thorough examination and chest X-ray. If the patient has an associated fever investigate as per pyrexia of unknown origin (for example, subacute bacterial endocarditis, malaria, tuberculosis)
    • rare conditions—if the attacks are associated with pallor, tremor, or headaches, consider a phaeochromocytoma or insulinoma. Ideally, the relevant investigations should be performed during an attack
  • Flushing, as opposed to sweating
    • flushing, as opposed to sweating, is likely to be associated with the menopause or rosacea
    • if patients are unwell during bouts of blushing, and have associated abdominal pain or diarrhoea, consider the carcinoid syndrome
  • The Ross syndrome—extensive anhydrosis leads to islands of compensatory hyperhidrosis. Patients also have Aide’s pupils (tonic pupils) and absent tendon reflexes.

Management

General management

  • Provide a patient information leaflet
  • Advise patients as follows:
    • use emollient washes rather than soap-based products
    • avoid tight clothing and man-made fabrics
    • wear leather shoes
  • Self-help products include:
    • foot wipes, spray, and gel
    • silver and copper socks
    • absorbent shoe insoles
    • disposable axillae pads.

Suggested treatments

For further information on the treatments suggested here, see Table 1

Generalised hyperhidrosis

  • Oral anticholinergics
  • Other treatments occasionally used include beta-blockers that cross the blood–brain barrier, for example, propranolol 40 mg three times a day, or diltiazem 60 mg three times a day, both of which can take several weeks to work
  • Other drugs such as clonidine, clonazepam, and indomethacin are probably of little value.

Palmar and plantar hyperhidrosis

  • Antiperspirants
  • Iontophoresis
  • Anticholinergics
  • Severe palmar hyperhidrosis: endoscopic thoracic sympathectomy (ETS).

Axillary hyperhidrosis

  • Antiperspirants
  • Botulinum toxin
  • Anticholinergics.

Craniofacial hyperhidrosis

  • Anticholinergics
  • Botulinum toxin
  • ETS.

Other focal hyperhidrosis

  • Topical anticholinergics
  • Botulinum toxin.

Table 1: Notes on suggested treatments

Treatment Information
Antiperspirants

Aluminium chloride antiperspirants are of most use in the axillae, but can also be used on the hands and feet

Apply at night only

Wash the area, dry before application, and wipe on once only

Wash off the following morning

Due to the irritant nature of the treatment start twice a week, and gradually increase by one night a week

If very irritable, use clobetasone butyrate 0.05% cream in the morning, or wash the area with a pinch of baking soda dissolved in water

A 2-week trial of antiperspirant is considered appropriate, and if successful, continue

Botulinum toxin

A series of injections is given intradermally, to block acetylcholine release and hence neurotransmission

It is best for the axillae (its only licensed use in hyperhidrosis) and other focal areas where the efficacious effects last about 4–8 months, after which time further treatment will be required

It is not as good for the feet and hands as local anaesthetic is needed, and it has a shorter duration of action

In a few cases, botulinum injection is available on the NHS, though mostly this is only available privately—check with local guidelines

Endoscopic thoracic sympathectomy (ETS)

ETS should only be considered when all other treatments have failed, as the compensatory sweating following this surgery can be much worse than the original problem

ETS can be performed as an open or endoscopic procedure

The main indications are resistant palmar or craniofacial cases; it is less successful for the axillae

The risk of compensatory hyperhidrosis is 60% and can be severe. There are also rare risks of pneumothorax or dysrhythmia at time of the procedure

Iontophoresis

Most dermatology departments treat palmar and plantar hyperhidrosis using iontophoresis and some treat the axillae

Iontophoresis is contraindicated if pregnant, or if the patient has a pacemaker or metal implant

If a course of treatment is successful it will need to be repeated as soon as the sweating resumes. For this the patient is encouraged to buy their own machine for home use, which often needs to be used once or twice a week

Oral anticholinergics

Systemic anticholinergics (SACs) are best used for generalised hyperhidrosis and compensatory sweating following ETS, as opposed to just one or two areas of hyperhidrosis

Propanthelene bromide is the only licensed systemic product for primary hyperhidrosis. Start at a low dose of 15 mg once to twice a day, increasing as tolerated to 30 mg three times a day

Some patients are unable to tolerate standard-release formulations of SACs, in which case consider a modified-release formula of oxybutynin 10 mg; the dose can be gradually increased up to a maximum of 30 mg once daily. If dry mouth is a problem, add in pilocarpine 10 mg three times a day

Consideration needs to be given to prescribing any long-term SACs in older people as there is a small amount of evidence connecting them with dementia

Topical anticholinergics (TACs)

TACs can be a useful adjunct for focal hyperhidrosis

Products containing glycopyrrolate, such as wipes and pads, can be purchased by patients

Occasionally 0.5% glycopyrronium bromide solution or glycopyrronium bromide cream (100 g) is prescribed, but is very expensive

Other treatments Surgery such as retrodermal curettage, liposuction, and laser sweat ablation is generally performed privately, but a few NHS hospitals provide some of these treatments. These treatments are only suitable for the axillae and have varying success rates

 

Full guideline: 

Primary Care Dermatology Society. Hyperhidrosis. PCDS, 2019. Available at: pcds.org.uk/clinical-guidance/hyperhidrosis.

Published date: 09 February 2014.

Last updated: 21 September 2019.