Overview

Excessive sweating that is not necessarily caused by heat or exertion is known as hyperhidrosis. Primary hyperhidrosis is produced by incorrect nerve impulses, which cause eccrine sweat glands to overwork. Endoscopic thoracic sympathectomy (ETS), a surgical technique, is the most effective therapy for hyperhidrosis.

What is Excessive Sweating (Hyperhidrosis)?

Hyperhidrosis is a condition characterized by excessive sweating caused by overstimulation of cholinergic receptors on eccrine glands. Sweating above what the body requires for homeostatic temperature regulation characterizes this condition. There are no rules to establish what "normal" sweating is, but if you feel you sweat excessively and it is interfering with your daily life, you may have hyperhidrosis.

The sweating may affect the whole of your body, or it may only affect certain areas. Commonly affected areas include the:

• Armpits
• Palms of your hands
• Soles of your feet
• Face and chest
• Groin

Typically, both sides of the body are afflicted equally, such as both feet or both hands. Because of the large number of sweat glands in the hands, feet, armpits, and groin, hyperhidrosis-related excessive sweating is most common there.

• Focal hyperhidrosis: When the excessive sweating is localized. For example, palmoplantar hyperhidrosis is excessive sweating of the palms and soles.
• Generalized hyperhidrosis: Excessive sweating affects the entire body.

The condition can be due to an underlying health condition, or have no apparent cause:

• Primary idiopathic hyperhidrosis: “Idiopathic” means “of unknown cause.” In the majority of cases, the hyperhidrosis is localized.
• Secondary hyperhidrosis: The person sweats excessively as a result of a medical condition such as obesity, gout, menopause, a tumor, mercury poisoning, diabetes mellitus, or hyperthyroidism (overactive thyroid gland).

What Causes Hyperhidrosis? 

Hyperhidrosis is classified as either primary or secondary. This difference is critical because therapy and management may differ dramatically between the two groups. Despite many literature studies, the cause of primary hyperhidrosis remains uncertain. Although the exact cause of excessive neuronal stimulation is unknown, genetic factors are thought to have a role.

Secondary causes are usually easier to identify because they are linked to medications like dopamine agonists, selective serotonin reuptake inhibitors (SSRIs), antipsychotics, and insulin; systemic disorders like diabetes, hyperthyroidism, Parkinson disease, and other neurologic disorders; and tumors like pheochromocytoma and lymphoma.

Hyperhidrosis can be caused by almost any febrile disease. Hyperhidrosis is also linked to chronic excessive alcohol intake and TB.

It is uncommon to develop segmental or regional hyperhidrosis. In certain people, the illness might manifest on the forehead, axilla, palm, foot, or forearm. Some postmenopausal women experience moderate to severe facial and scalp hyperhidrosis. Unilateral hyperhidrosis is more prevalent on the right side of the face or arm, whereas anhidrosis is more common on the left.

Signs and Symptoms of Hyperhidrosis

Excessive sweating is reported by hyperhidrosis patients, frequently in areas with the largest density of eccrine glands, such as the palms, soles, face, head, or axillae. Primary hyperhidrosis is more frequent in young people, those who have had symptoms for more than six months, those who have a family history of the illness, and those who have bilateral involvement.

Symptoms that appear later in life are more likely to be caused by a secondary cause, and a workup to rule out pharmaceutical side effects or systemic illness is recommended. Clinical examination is frequently used to make a diagnosis; hence a visual inspection of the common areas is advised. There are visual scales that can be used to assess the severity of palmar sweat. When localization is in doubt, an iodine-starch test can help localize the areas of concern, which is also useful during treatment.

Diagnostic criteria for primary hyperhidrosis:

1. Excessive sweating for 6 or more months
2. Sweating involves axilla, palms, soles, and/or face
3. Sweating is bilateral and symmetric
4. Decreased or no sweating at night
5. Sweating episodes last at least 7 days
6. The individual is 25 years of age or younger
7. There is a family history
8. Sweating impairs daily living activities

How is Hyperhidrosis Diagnosed?

Your doctor will ask about your medical history, including diseases you've been diagnosed with and drugs you're presently on, to diagnose hyperhidrosis. A physical examination and lab testing may also be ordered by your doctor. A urine and blood test may be performed to look for an overactive thyroid or low blood sugar. Excessive sweating can be caused by either of these conditions.

You may also require a sweat test, which your doctor will use to identify the areas of your body that sweat excessively. Your doctor will apply a powder substance to various areas of your skin for this test. As you sweat, the powder turns purple.

Although you are not required to see your family doctor or a dermatologist for this problem, you should schedule an appointment if your sweating becomes severe or if you develop additional symptoms such as chest pains, nausea, light-headedness, or night sweats. This might be an indication of a major medical concern.

How Has Excessive Sweating Affected Your Mental Health?

Sweating without a recognized reason, such as a hot day or a strenuous workout, is a telltale sign of hyperhidrosis. However, the repercussions of excessive sweating go beyond the skin, since persons with hyperhidrosis are more likely to suffer from mental health conditions such as anxiety and sadness.

Everyday circumstances such as riding the metro, dining out, or traveling to a shared working environment — all of which necessitate being in public view and interacting with others — can be emotionally draining for persons with hyperhidrosis. Indeed, in a nationally representative survey of 393 adults with excessive sweating, 72% said the disease has a detrimental impact on their mental health.

How Hyperhidrosis is Treated?

Clinicians' lives have been simpler as more treatment alternatives have become accessible, and a progressive approach is generally beneficial. To treat hyperhidrosis, there are both topical and systemic medicines available.

Over-the-counter aluminum chloride hexahydrate 20% for 3 to 4 nights, then nightly as required, is first-line treatment for hyperhidrosis. Skin irritation can occur, and patients frequently develop tolerant of it over time.

Topical glycopyrronium tosylate (premoistened cloth with 2.4% glycopyrronium solution) was recently approved for the treatment of excessive perspiration. Aluminum chloride gel can be used to treat axillary perspiration. While it works, it is a strong irritation.

Skin sensitization can be caused by any topical substance, and some, such as tannic acid and potassium permanganate, can also produce skin coloring. These compounds appear to reduce sweating by denaturing keratin and thereby occluding sweat gland pores. The effect lasts only a few seconds.

If a patient does not respond to topical treatment or has more widespread symptoms, oral anticholinergic medications such as oxybutynin 5 mg to 10 mg per day or topical glycopyrrolate 0.5% to 2.0% should be considered. Dry eyes, dry mouth, urinary retention, and constipation can all be side effects of anticholinergic medications.

Botulinum toxin and iontophoresis two to three times each week If patients fail topical and oral medication treatment, A injections every 3 to 4 weeks are useful. Iontophoresis is a long-term therapy with just minor side effects. Although several agents can be added to the water, compliance with this treatment is low.

Botulinum toxin is effective; nevertheless, it is costly, and it must be repeated. Some specialists advise injecting botulinum toxin with lidocaine into the axilla. This hinders the binding and presynaptic fusion of cholinergic vesicles with the nerve terminal, hence blocking acetylcholine release.

It is the best option when topical antiperspirants and oral anticholinergics have failed. Perspiration can be reduced for 6 to 24 months. Injections are typically administered in both axillae; however, they can also be administered in the palms and soles. These locations are less practical and will almost certainly necessitate local anesthesia to alleviate discomfort.

Endoscopic Thoracic Sympathectomy (ETS)

Although it is considered a last resort by healthcare practitioners, surgery is another option for treating excessive perspiration when medication alternatives fail. Endoscopic thoracic sympathectomy (ETS), also known as thoracoscopic sympathectomy, is a surgical procedure that involves cutting the nerves in your sympathetic nervous system that cause localized sweating. When the patch is effective, it is permanent.

If traditional first-line therapies haven't helped with obstinate hyperhidrosis in your hands or armpits, your doctor may consider this minimally invasive surgery.

You'll be sedated during this procedure while a surgeon makes two or three incisions in your armpit on the side of your body where you're prone to hyperhidrosis. One of your lungs will be temporarily collapsed to prevent airflow during surgery and to provide extra space for the procedure.

Through one of the cuts, the surgical team will implant an endoscope, which is a small camera. This allows the surgeon to see into your chest via a monitor while doing the surgery. When the surgeon locates the nerve responsible for your excessive sweat glands, he or she will destroy, clip, or cut it. Your deflated lung will then be reinflated, and the wounds will be sewn up. Depending on the severity of your hyperhidrosis, the surgeon may repeat the treatment on the other side of your body.

Typically, the treatment takes one to three hours to complete. The advantages of this surgery include a brief hospital stay and, in most cases, a speedy recovery. The risks, on the other hand, include developing gustatory sweating, or sweating while eating. Gustatory sweating affects 5 to 10% of people who have ETS.

More typically, you may start sweating excessively in places of your body where you did not previously. This sort of sweating, known as compensatory hyperhidrosis, affects over 70% of those who have this treatment.

Horner's syndrome is a rare complication of ETS that can occur as a result of nerve injury during the operation. This condition might cause your pupil to seem smaller, your eyelids to droop, or you to sweat on only one side of your face. This negative effect may fade with time.

Again, ETS is permanent. There have been no reports of successful reversal of this operation.

Side effects

Every surgery involves some level of risk. When sweat glands in the underarm are removed, there is a risk of infection. Patients may experience pain and bruises. These will vanish. Permanent side effects are also possible. Scarring and loss of sensation in the underarm are also potential outcomes.

Endoscopic surgical advances have minimized some of the dangers associated with sympathectomy. Serious adverse effects are still possible. Compensatory sweating is a condition that certain people acquire. This causes some people to sweat more excessively than hyperhidrosis did.

Damage to the nerves that go between the brain and the eyes, severely low blood pressure, erratic pulse, and inability to tolerate heat are all possible adverse effects of sympathectomy. Patients have perished as a result of this operation.

Alternative and Complementary Therapies

Iontophoresis is an alternative therapy that may help with hyperhidrosis symptoms. This technique, which can be done at home, uses an electrical current to temporarily stop sweat glands in specific areas of the body. It is a treatment option for excessive sweating in the hands or feet.

Simply put your hands or feet in a small pan of water. With your feet or hands in the water, the gadget sends a moderate electrical current through the water, disturbing your sweat glands. This treatment is successful, but it takes time. You may require two to three sessions each week, each lasting up to 40 minutes. The outcomes are just transient.

Herbal medicines such as sage, chamomile, and St. John's wort are among the natural remedies for hyperhidrosis. Before using herbal supplements, see your doctor, especially if you are using prescription drugs.

Unfortunately, there has been insufficient evidence to support the efficacy of these medicines. Acupuncture for hyperhidrosis may also be beneficial. Three persons with primary hyperhidrosis were given 20 to 25 acupuncture treatments over the course of a few months in a previous research. All individuals reported a reduction in perspiration and no negative effects from the therapy.

Complications of Hyperhidrosis

Excessive sweating may appear to be a small irritation, but hyperhidrosis can cause medical and psychological suffering depending on its degree. Fungus may develop and thrive in a damp environment caused by hyperhidrosis. Sweating excessively in your groin area might make you prone to jock itch, and if your feet sweat excessively, you may get athlete's foot. It can also cause fungal nail infections and body odor.

Excessive perspiration can also cause skin breakdown, enabling germs and viruses to enter and cause skin illnesses such as warts. According to a study published in the American Journal of Managed Care in December 2018, persons with hyperhidrosis had a 300 percent increased risk of skin infections.

Furthermore, excessive perspiration might make you feel awkward in social situations. You may avoid activities or gatherings due to shame or fear of obvious sweat. It also discourages some people from pursuing educational and professional aspirations.

Conclusion 

Hyperhidrosis is a dangerous medical disorder marked by uncontrolled perspiration. Primary and secondary hyperhidrosis are distinguished by major differences in management and therapy. The main ailment usually manifests itself early in life and with more localized symptoms. Secondary illness often manifests as a result of pharmaceutical side effects or systemic conditions, particularly neurologic problems.

Clinical diagnosis is most typically made, and grading scales and tests are available to aid in identifying severity and location. If a secondary cause is suspected, a laboratory workup may be recommended to rule out infection, hyperthyroidism, diabetes mellitus, a neurologic condition, or a pharmaceutical side effect.

Treatment options for hyperhidrosis include topical aluminum chloride and oral anticholinergic drugs, which are adequate in people with mild to severe illness. Botulinum toxin A injections, sympathectomy, and local excision are also beneficial but should only be used in individuals who have failed conservative treatment.