CKS: Clinical Solutions - Hyperhidrosis

The Case: A 25-year-old woman presents complaining of excess sweating. She is becoming increasingly embarrassed by the problem.

Aluminium chloride may help
Aluminium chloride may help

What is hyperhidrosis?
Hyperhidrosis, or excessive sweating, can be classified as focal or generalised and by the presence of an underlying cause (primary or secondary).

Primary focal hyperhidrosis may affect the axillae, hands, feet, face or scalp, and has no underlying cause.1 Secondary focal hyperhidrosis is caused by an underlying condition (e.g. neuropathy).2

Generalised hyperhidrosis affects the entire skin surface area and is usually secondary to other medical conditions or induced by drugs.3

How should I assess the patient?
Look for a cause, especially in generalised sweating, sweating during sleep (possible TB), associated fever or weight loss, taking medication known to cause sweating or if sweating is unilateral or asymmetric (possible neurological lesion or tumour).

Assess whether anxiety may be an exacerbating factor.

Primary focal hyperhidrosis
Diagnose primary focal hyperhidrosis when visible, focal, excessive sweating occurs in at least one of the following sites: axillae, palms, soles or craniofacial region, lasting at least six months, with no apparent cause, and with at least two of the following characteristics: bilateral and relatively symmetrical; impairs daily activities; frequency of at least one episode per week; onset before 25 years of age; positive family history and cessation of local sweating during sleep.

How should I manage primary focal hyperhidrosis?
For primary focal hyperhidrosis, advise avoidance of food and drink triggers. Advise use of an antiperspirant and to avoid tight clothing and manmade fabrics.

Advise moisture-wicking socks, absorbent soles and absorbent foot powder. Avoid occlusive footwear.

Advise on the use of 20 per cent aluminium chloride hexa-hydrate solution, which can be prescribed or bought OTC. It should be applied at night and washed off in the morning.

For the feet, an aluminium salt dusting powder can be used as an alternative, but advise the patient to watch for skin irritation.

Review the patient one to two months after starting treatment. If successful, it can be continued indefinitely. Treat underlying anxiety, preferably with CBT.

Refer to a dermatologist if the treatments are inadequate or unacceptable.

Secondary focal or generalised hyperhidrosis usually requires referral.

Evidence
The diagnosis recommendations are based on a US expert consensus statement,1 and the use of these diagnostic criteria is widely advocated.3-6

CKS found no randomised, placebo-controlled trials of the efficacy and safety of aluminium salts for the treatment of primary focal hyperhidrosis. These recommendations are based on poor quality evidence from two small, quasi-controlled trials,7 case series and expert opinion, including two published consensus statements,1,6 two guidelines2,3 and an evidence-based review.8 Lifestyle advice and management of generalised or focal hyperhydrosis is based on expert opinion.1,2

Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP. See www.cks.nhs.uk

References

1. Hornberger J, Grimes K, Naumann M et al. J Am Acad Dermatol 2004; 51(2): 274-86.

2. Lowe NJ, Cliff S, Halford J et al. eGuidelines 2003; 19(Feb): 373-7.

3. International Hyperhidrosis Society. Generalized hyperhidrosis. 2008. www.sweathelp.org (Accessed: 20/02/2009).

4. Glaser DA, Hebert AA, Pariser DM, Solish N. Cutis 2007; 79(5 Suppl): 5-17.

5. Gee S, Yamauchi PS. Thorac Surg Clin 2008; 18(2): 141-55.

6. Solish N, Wang R, Murray CA. Thorac Surg Clin 2008; 18(2): 133-40.

7. Rayner CR, Ritchie ID, Stark GP. BMJ 1980; 280(6224): 1168.

8. DTB, 2008 - is this: DTB (2005) Treatments for excessive armpit sweating. Drug & Therapeutics Bulletin 43(10), 77-80.

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