Hyperhidrosis

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Hyperhidrosis

Hyperhidrosis

Doc, I’m so embarrassed. My sweating is out of control! I change my shirt twice a day, my shoes get ruined and I can’t write without making the paper wet…”

Hyperhidrosis is a chronic condition involving overreactive sweat glands. True prevalence is unknown because of underreporting and underdiagnosis. It can severely affect patients’ quality of life, relationships and work. This article is drawn from a BJGP Clinical Practice piece on the topic (BJGP 2024;74:236).

This article was written in October 2024.

Causes and categories

Assessment and investigation

  • History should include:
    • Distribution of sweating, onset, timings and triggers.
    • Psychosocial impact.
    • Drug history, family history and comorbidities.
    • Associated symptoms, e.g. weight loss, palpitations (if there are night sweats, be particularly cautious about excluding infection and malignancy).
  • Examination should look for:
    • Signs of any underlying condition.
    • Signs of any complications such as intertrigo or bacterial skin infection.
  • If a specific secondary cause or causes are suspected, tailor investigations to these and refer as appropriate.
  • If symptoms and signs are non-specific, the BJGP article suggests these investigations:
    • FBC, U&Es, CRP, LFTs, TFTs, HbA1c.
    • Chest X-ray.

Management

The BJGP doesn’t specify whether these management strategies are for primary or secondary hyperhidrosis, and we take this to mean that they can be used in either. The important thing to remember is that the treatment of secondary hyperhidrosis also involves addressing the underlying cause where possible!

Simple patient-initiated measures
  • Loose clothing made from natural fibres.

  • Leather shoes, open design if possible.

  • Over-the-counter antiperspirants.

  • Underarm pads.

  • Moisture-wicking socks and insoles.
    		•
    Prescribable in primary care
  • Topical aluminium chloride antiperspirants

    • Can be used on either a PRN or regular basis.

    Up to 80% effective in mild to moderate hyperhidrosis.

    Apply on clean, dry skin at night and wash off in the morning.

    Can cause skin irritation: treat with mild topical steroids if needed.

    The BJGP piece recommends a 6w trial of topical aluminium chloride antiperspirants before moving on to other measures.
  • Oral oxybutynin

    • Not licensed for hyperhidrosis so the usual patient discussions are needed, but endorsed by NICE in an evidence summary (NICE 2017, ES10).

    The BJGP states that it can be initiated for hyperhidrosis in primary care, suggesting dosing of 2.5mg OD and increased gradually to 5mg BD as tolerated.
    Secondary care (dermatology)
  • Higher-strength aluminium chloride preparations.

  • Oral treatments, including propantheline bromide, beta-blockers, calcium channel blockers and glycopyrronium.

  • Iontophoresis (involves passing an electric current through an ion-rich medium in which the affected part of the body is placed).

  • Botox.

  • Surgical or laser removal of sweat glands.

  • Endoscopic thoracic sympathectomy: reserved for extreme cases. Involves cutting the sympathetic chain as it passes through the pleural cavity. Complications include pneumothorax, pneumonia, pain, bleeding and compensatory sweating.

  • Emerging treatments not yet available in the UK include topical glycopyrronium and ‘targeted alkali thermolysis’ patches.
    		•
    Hyperhidrosis
  • Can be primary or secondary, and localised or generalised. Generalised hyperhidrosis is usually secondary.

  • An important goal of assessment is to exclude serious underlying causes; this should usually include examination, bloods and a chest X-ray.

  • Initial management includes simple lifestyle measures and a 6w trial of topical aluminium chloride antiperspirant. If these fail, we can consider oral oxybutynin in primary care and/or dermatology referral.
    		•
    Useful resources:
    Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge)
  • Hyperhidrosis UK – patient support group
  • International Hyperhidrosis Society
    		•

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