What You Should Know About Managing Hyperhidrosis

By Mary E. Crawford, DPM, FACFAS

Hyperhidrosis is a pathological condition of overperspiration due to excessive secretion by the eccrine sweat glands in amounts greater than required for physiological needs. The disorder often leads to personal embarrassment and professional difficulties in the workplace. It is estimated that Americans alone spend in excess of $500 million annually on products designed to decrease sweating. Patients will often seek medical attention but the enormity of the problem is often disregarded by the medical professional, resulting in despair and isolation for those who suffer from hyperhidrosis. It behooves all treating physicians to acquire the knowledge necessary to diagnose and treat the various causes of hyperhidrosis appropriately. Primary hyperhidrosis, also known as idiopathic, localized or essential hyperhidrosis, is a disorder of sweating characterized by an exaggerated response of both the eccrine and aprocrine sweat glands to a normal stimulus, which is usually an emotional stimulus. The disorder predominantly affects the palms, soles and axillae, and is not associated with any underlying systemic disease. The symptoms usually present early in life, generally before the age of 20. Unfortunately, there is no known cause for primary hyperhidrosis, making it difficult to eradicate. The most focal form of hyperhidrosis is palmoplantar hyperhidrosis, which affects only the palms of the hand and the sole of the foot. Secondary hyperhidrosis occurs in association with a systemic disease or underlying condition, and results in generalized hyperhidrosis that usually responds to the removal or control of the causative agent. Conditions that may lead to secondary hyperhidrosis include metabolic diseases such as thyrotoxicosis, diabetes mellitus, hypoglycemia, pheochromocytoma, hyperpituitarism; medications such as propanolol, tricyclic antidepressants, serotonin reuptake inhibitor antidepressants; and neurological conditions such as Riley-Day syndrome, autonomic dysreflexia and hypothalamic lesions. The onset of secondary generalized hyperhidrosis is usually in adulthood when the disease process occurs or the medication is prescribed. The examining physician must differentiate the type of hyperhidrosis present and search for any underlying causes before presuming primary hyperhidrosis. Recognizing The Clinical Signs And Symptoms Of Primary Hyperhidrosis Patients suffering from primary hyperhidrosis usually complain of excessive moisture on the socks or within the shoes; moisture or damage to their clothing due to chemicals combined with the sweat; and offensive odor. The increased moisture on the skin results in an increased incidence of contact dermatitis, blistering and dermatophyte, bacterial and viral infections. Disease conditions such as tinea pedis, verruca and pitted keratolysis commonly occur with hyperhidrosis. The physical examination often reveals two different hyperhidrotic foot types. The first type will present with visible moisture on the feet in small droplets in a moccasin distribution. The second type shows no visible droplets. However, the skin is very white and macerated from the moisture being absorbed and contained within the skin itself. There is a variant of the second type known as symmetrical lividity of the soles as described by Pernet in 1925. This hyperhidrotic foot presents with symmetrical soggy white hyperkeratotic plaques with sharp bluish-red margins. As the sweat is trapped in the plantar skin, this foot type is often associated with bromhidrosis (odiferous hyperhidrosis) and an increased incidence of infectious organisms. Understanding The Pathophysiology Of Hyperhidrosis There are 3 to 4 million sweat glands over the body surface, which allows for evaporation to cool the body and protect it from overheating. There are two types of sweat glands, the eccrine gland and the aprocrine gland. Eccrine glands are present all over the body but are primarily concentrated in the palms, soles and axillae. They make up the majority of the sweat glands and are responsible for the bulk of the sweat produced for thermoregulation. The sympathetic nervous system innervates the eccrine glands and stimulates activity through the release of acetylcholine. The sweat produced is an aqueous solution rich in electrolytes and is usually released in response to emotional stimuli or environmental stimuli such as high temperature, humidity or exercise.

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