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Manifestations of Primary Hyperhidrosis

Facial Hyperhidrosis - sweat pouring down from the forehead in conditions of stress can be very distressful, inducing the patient to think that others may consider him/her nervous and insecure.

Axillary Hyperhidrosis - also hyperhidrosis of the armpits can be embarrassing causing large wet marks and sometimes a white halo of salt from sweating on the cloths.

Palmar Hyperhidrosis - excessive sweating of the hands is, generally, by far the most distressing condition. The hands are much more exposed in social and professional activities than any other part of our body. Many individuals with this condition are limited in their choice of profession, because unable to manipulate materials sensitive to humidity (paper etc) or reluctant to shake hands; some patients arrive to the point to avoid social contact. The degree of sweating varies and may range from moderate moisture to dripping. Most patients notice that their hands not only feel moist, but also cold.

Plantar Hyperhidrosis (other locations) - Less frequently, it is located only to the trunk and/or the thighs. Other patient are suffering from copious sweating in the face.

• Sweating can appear suddenly or manifest itself more continuously
• Many individuals suffer form a combination of the above cathegories
• It can be elicited by high outside temperatures or emotional stress, or appears without any obvious reason.

Generally, it worsens during the warm season and gets better during winter


Causes

• primary = essential = idiopathic (unknown cause)
• secondary (known cause)

Locations

• palmar (hands)
• plantar (feet)
• axillary (armpits)
• truncal (trunk)
• facial (face)
• general

1) Hyperhidrosis as part of an underlying condition (secondary hyperhidrosis).

Some conditions can promote excessive sweating, as a rule involving the whole body:

• Obesity
• Menopause
• Hyperthyroidism or similar endocrine diseases
• Endocrine treatment for prostatic cancer or other types of malignant disease
• Severe psychiatric disorders

2) Hyperhidrosis without known cause (=primary or essential hyperhidrosis)

This is a far more frequent condition than secondary hyperhidrosis and appears, generally, localized in one or several locations of the body. It usually starts during childhood or adolescence and persists all life. Nervousness and anxiety can elicit or aggravate sweating, but psychological/psichiatric disturbances are only rarely the cause of the disorder.

Treatment

In patients with primary hyperhidrosis or for symptomatic treatment of heavy sweating in patients with secondary hyperhidrosis, not treatable otherwise, the following methods have been adopted. In psychiatric patients with hyperhidrosis, successful treatment this symptom often reduces the tendency towards emotional distress.

In secondary hyperhidrosis, the underlying condition should be treated first. Patints on hormonal therapy for prostatic cancer (castration, LHRH-analoges) with disturbing sweat attacks can get relief by the administration of antiestrogens (ciproterone acetate).

• Antiperspirants - usually recommended as the first therapeutic measure. The most effective agent appears to be alluminum chloride (20-25%) in 70-90% alcohol, applied in the evening 2-3 times/week. Generally, this treatment is sufficient in cases with light to moderate hyperhidrosis but has to repeated regularly.
• Botulinum Toxin - a family of toxins produced by a bacteria known as Clostridium botulinum. This toxin is one of the most lethal poisons known, interfering with the effect of the transmitter substance acethylcholine at the synapses (the contact point of a nerve ending with another nerve cell or a muscle) and leading to progressive paralysis of all muscles in the body, including the respiratory muscles. In extremely low doses, botulinus toxin has been adopted in cases with localized muscle hyperactivity (lid spasms, torticollis, etc), resulting in a reduction in transmitting impulses to the muscle. Initial reports have been published regarding the use of botulinum toxin in hyperhidrosis. It seems to work adequately in axillary hyperhidrosis, lasting for 6-12 months depending on the dosage (0.5-1.0 Units/cm2;). A drawback are the costs of this treatment which has to be repeated at regular intervals, but the side-effects seem to be negligible if dosages are kept low.
• Drugs - there are no specific drugs available against profuse sweating. Psychotropic (mostly sedative) and/or anticholinergic drugs are often tested but show usually too many side-effects before any noticeable result can be achieved. Hence, they are, as a rule, not recommended. In those few cases who suffer from profuse sweating on the trunk (but not the extremities), a low dose of anticholinergic agent can slightly alleviate the symptoms without rendering life unsupportable from side-effects (dry mouth, accomodation difficulties of the eyes, etc), but a dosage necessary to normalize the amount of sweating will rarely be tolerated.
• Iontophoresis - can be tried if antiperspirants have not lead to the desired result. This method consists in applying low intensity electric current (15-18 mA), supplied by a D/C generator, to the palms and/or soles immersed in an electrolyte solution. The procedure has to be repeated regularly, initially in 20' sessions several times/week, gradually stretching out the interval between treatments to 1-2 weeks. The results vary: many patients, suffering from light or moderate hyperhiderosis, are happy with the method, some may consider it too time-consuming or inefficient, and comparably expensive. It is difficult to apply in axillary, and impossible to use in diffuse hyperhidrosis of the face or the trunk/thigh region.
• Surgery - 1) Excision of the axillary sweat glands: Patients with axillary hyperhidrosis who are unresponsive to medical therapy can be effectively treated by excision of the axillary sweat glands. If sweating extends beyond the hairy portion of the axilla, several skin incisions may be needed, sometimes resulting in formation of hypertrophic and/or constrictive scars. 2) Sympathectomy:
  - The principle of sympathectomy is to interrupt the nerve tracks and nodes (ganglia) which transmit the signals to the sweat glands. Basically, this can be achieved for all locations in the body, but only the nerve nodes responsible for the sweat glands of the palms and the face are accessible without the need for a major surgical procedure. Today, the treatment of choice for moderate to severe palmar and facial hyperhidrosis (but also axillary, especially if combined with palmar sweating), consists in a surgical procedure known as Endoscopic Thoracic Sympathectomy. This minimal-invasive endoscopic technique has been developed in recent years in a few hospitals in Europe, superseeding Conventional Thoracic Sympathectomy, a very traumatic procedure performed in the past. The endoscopic technique is very safe, if performed by a surgeon experienced in this type of procedure, and leads to definitive cure in nearly 100% of patients, leaving only a minimal scar in the armpit.
  - Diffuse hyperhidrosis of the trunk or general sweating of the whole body cannot be treated by surgery.
  - Individuals with combined hyperhidrosis of the palms and soles have a good chance to improve the sweating of their feet after an operation aiming to suppress sweating of the hands. Isolated plantar hyperhidrosis can, however, only cured by Lumbar Sympathectomy, an open abdominal procedure.
  

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