This document discusses hyperhidrosis (excessive sweating), covering its epidemiology, etiology, pathophysiology, diagnosis, and treatment. It notes that hyperhidrosis is caused by overstimulation of cholinergic receptors, and can have physical and social impacts. The diagnosis involves examining family history and sweat production; and treatments include topical anticholinergics, oral medications, iontophoresis, botulinum toxin injections, and sympathectomy for severe cases. The summary emphasizes that hyperhidrosis affects patients' physical and psychological health as well as their quality of life.

1. Hyperhidrosis
Ade Wijaya, MD
October 2019

2. Outline:
• Introduction
• Epidemiology
• Etiology
• Pathophysiology
• Diagnosis
• Treatment and management
• Summary

3. Introduction
• A disorder of excessive sweating due to over-
stimulation of cholinergic receptors on eccrine
glands
• Physical discomfort and social embarrassment
 functionally morbid and disabling
Sammons JE, Khachemoune A. Axillary hyperhidrosis: a focused review. J Dermatolog Treat. 2017 Nov;28(7):582-590.
Perri, B., Vaynman, S., Ghostine, S., Samudrala, S., Johnson, J. P., & Siddique, K. (2016). Hyperhidrosis: pathophysiology and available therapies. Surgery of the Autonomic Nervous System, 285.

4. Epidemiology
• 3 % in USA
• 1 % in Western population
• 0.15 – 0.25 % Israeli population
• 0.05 % in the Japanese or other asian ethnic
population
• Onset: childhood and adolescence in primary
hyperhidrosis; later age onset  secondary
Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J. Am. Acad. Dermatol. 2004
Aug;51(2):241-8.
Perri, B., Vaynman, S., Ghostine, S., Samudrala, S., Johnson, J. P., & Siddique, K. (2016). Hyperhidrosis: pathophysiology and available therapies. Surgery of the Autonomic Nervous System, 285.
Menzinger S, Quenan S. [Evaluation and management of hyperhidrosis]. Rev Med Suisse. 2017 Mar 29;13(556):710-714.

5. Etiology
• Primary  genetics
• Secondary  medications such as dopamine
agonists, SSRIs, antipsychotics, alcohol, and
insulin, systemic disorders such as diabetes
mellitus, hyperthyroidism, Parkinson disease, and
other neurologic disorder, and tumors such as
pheochromocytoma and lymphoma, also chronic
infections, dermatological ailments.
Romero FR, Haddad GR, Miot HA, Cataneo DC. Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. An Bras Dermatol. 2016 Nov-Dec;91(6):716-725.
Perri, B., Vaynman, S., Ghostine, S., Samudrala, S., Johnson, J. P., & Siddique, K. (2016). Hyperhidrosis: pathophysiology and available therapies. Surgery of the Autonomic Nervous System, 285.

6. Pathophysiology
• Sweating beyond what the body uses for
homeostatic temperature regulation
• Eccrine glands are concentrated in areas such as
the axillae, palms, soles, and face, so these are
the areas most commonly affected by
hyperhidrosis
• The acetylcholine negative feedback loop is likely
impaired in these patient's which may help
explain how a physiologic response can become
pathologic
Menzinger S, Quenan S. [Evaluation and management of hyperhidrosis]. Rev Med Suisse. 2017 Mar 29;13(556):710-714.
Romero FR, Haddad GR, Miot HA, Cataneo DC. Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. An Bras Dermatol. 2016 Nov-Dec;91(6):716-725.

7. Pathophysiology
• hyperactivity of the sympathetic nervous
system  excessice release of acethylcoline
• Acetylcholine will innervate the epidermal
eccrine sweat glands as a physiologic response
to core body temperature control during times
of physical or psychological stress
Fujimoto T. Pathophysiology and Treatment of Hyperhidrosis. Curr. Probl. Dermatol. 2016;51:86-93.
Romero FR, Haddad GR, Miot HA, Cataneo DC. Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. An Bras Dermatol. 2016 Nov-Dec;91(6):716-725.

8. Diagnosis
• History and Physical
• Laboratory
• Radiology
• Histopatology
Brackenrich, J., & Fagg, C. (2018). Hyperhidrosis. In StatPearls [Internet]. StatPearls Publishing.

9. History and Physical
• Location
• Family history
• Iodine-starch test
Romero FR, Haddad GR, Miot HA, Cataneo DC. Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. An Bras Dermatol. 2016 Nov-Dec;91(6):716-725.
Menzinger S, Quenan S. [Evaluation and management of hyperhidrosis]. Rev Med Suisse. 2017 Mar 29;13(556):710-714.

10. Laboratory & Radiology
• A complete blood count
• Basic metabolic panel
• Thyroid-stimulating hormone
• Chest x-ray
• Sedimentation rate
• ANA
• Hemogblin A1C
Nawrocki S, Cha J. The Etiology, Diagnosis and Management of Hyperhidrosis: A Comprehensive Review. Part I. Etiology and Clinical Work-Up. J. Am. Acad. Dermatol. 2019 Jan 30;
Menzinger S, Quenan S. [Evaluation and management of hyperhidrosis]. Rev Med Suisse. 2017 Mar 29;13(556):710-714.

11. Histopathology
• Eccrin glands  normal size
• Larger sympathetic ganglia
Romero FR, Haddad GR, Miot HA, Cataneo DC. Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. An Bras Dermatol. 2016 Nov-Dec;91(6):716-725.

12. Treatment and Management
• First line: Anticholinergics
Aluminum chloride hexahydrate 20% (Drysol) for 3
to 4 nights then nightly as needed. Mild skin
irritation may result from the application
If a patient does not respond to topical treatment
or there are more generalized symptoms, oral
anticholinergic medications which block the
cholinergic receptors (including oxybutynin 5 mg
to 10 mg per day or topical glycopyrrolate 0.5% to
2.0%)
Delort S, Marchi E, Corrêa MA. Oxybutynin as an alternative treatment for hyperhidrosis. An Bras Dermatol. 2017 Mar-Apr;92(2):217-220.
Fujimoto T. Pathophysiology and Treatment of Hyperhidrosis. Curr. Probl. Dermatol. 2016;51:86-93.

13. Treatment and Management
Iontophoresis
- First introduced by Bouman et al. In the 1950s
- Applying a low level electric current 15-20 mA
to the skin under an electrolyte solution for 30
minutes
Perri, B., Vaynman, S., Ghostine, S., Samudrala, S., Johnson, J. P., & Siddique, K. (2016). Hyperhidrosis: pathophysiology and available therapies. Surgery of the Autonomic Nervous System, 285.

14. Treatment and Management
• Botulinum toxin A injections every 3 to 4
weeks if patients fail topical and oral
medication therapy
• Sympathectomy or local excision
• Treatment of the underlying disorder or
discontinuing the suspected medication
Hosp C, Hamm H. Safety of available and emerging drug therapies for hyperhidrosis. Expert Opin Drug Saf. 2017 Sep;16(9):1039-1049.
Al-Hashel JY, Youssry D, Rashaed HM, Shamov T, Rousseff RT. Botulinum toxin A for palmar hyperhidrosis: assessment with sympathetic skin responses evoked by train of stimuli. Auton
Autacoid Pharmacol. 2016 Jul;36(3-4):23-26

15. Summary
• Hyperhidrosis can affect not only a patient's
physical health but also his or her
psychological health.  affect QOL
• Excessive sweating; overstimulation of
cholinergic receptors
• Primary vs secondary