Clinical review
Recognition, diagnosis, and treatment of primary focal hyperhidrosis

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Methods

A multidisciplinary task force of internationally recognized experts was convened to review the clinical evidence and develop this consensus statement. The task force employed an evidence-based approach, performing a comprehensive literature search of English language articles.

After searching the literature, we rated each article based on the strength of the evidence presented in the report. We included English-language reports published between 1966 and 2002 that included original research on

Scope

This recommendation and consensus statement addresses the management of patients with excessive sweating localized to the armpits, palms, soles, or face that cannot be identified as secondary to another underlying disease process. Dermatological and neurological experts who specialize in the management of focal primary hyperhidrosis report that patients often have been misdiagnosed or mismanaged in their initial physician encounters. Experts generally perceive that they see only a small

Recommendation

When performing a medical evaluation, the review of systems should include questions regarding problematic excessive sweating.

Discussion

Physicians and patients frequently fail to recognize that primary focal hyperhidrosis is a relatively common and treatable medical condition. Aside from a pilot study of young Israelis that reported an incidence of 1%, the frequency of this condition in the general population is not well documented.1 A recent survey of the US population found a prevalence of 2.8%. Only

Recommendation

Primary focal hyperhidrosis is defined as excessive, bilateral, and relatively symmetric sweating occurring in at least one of the following sites: the axillae, palms, soles, or craniofacial region. Primary focal hyperhidrosis frequently results in occupational, psychological, and physical impairment, and can result in social stigmatization. The following criteria are recommended for establishing the diagnosis of primary focal hyperhidrosis:

Focal, visible, excessive sweating of at least 6

Recommendations

  • 1.

    The history should include questions about the following items:

    • a)

      pattern of sweating (duration of symptoms, frequency, volume, areas involved, symmetry, specific triggers, presence of sweating during sleep);

    • b)

      age of onset;

    • c)

      impact on daily activities/quality of life;

    • d)

      family history;

    • e)

      review of systems to exclude secondary causes;

    • f)

      symptoms that suggest systemic disease (eg, constitutional symptoms of fever, weight loss, anorexia, palpitations), signs and symptoms of thyroid and neurological disease.

  • 2.

    The

Recommendations (Fig 1)

  • 1.

    Ensure that the patient has appropriately used an over-the-counter antiperspirant. If necessary, educate the patient about the difference between antiperspirants and deodorants.

  • 2.

    Initiate topical therapy with AlCl hexahydrate after educating the patient on proper use.

    • a)

      Most patients benefit from a trial of topical AlCl hexahydrate in absolute alcohol or in a salicylic acid gel. Although a 25% solution may be required to achieve euhidrosis, an initial concentration of 10%-12% may be tried to

Recommendations (Fig 2)

  • 1.

    Initiate topical therapy with AlCl hexahydrate after educating the patient on proper use.

    • a)

      Some patients will benefit from a trial of topical AlCl hexahydrate in absolute alcohol or in a salicylic acid gel. An initial concentration of 10%-12% may be tried to minimize irritation, although a 25% solution is required to achieve euhidrosis in the majority of patients. Some patients tolerate a 35% solution, although this significantly increases the risk of intolerable skin irritation.

    • b)

      To minimize

Recommendations

  • 1.

    Educate the patient regarding local hygiene measures including changing the socks at least twice daily, using an absorbent foot powder twice daily, and alternating pairs of shoes on a daily basis to allow full drying before wearing. Avoid boots or sports shoes, which may have an occlusive effect.

  • 2.

    Initiate therapy with topical AlCl hexahydrate in a regimen similar to that for palmar hyperhidrosis.

  • 3.

    Tap water iontophoresis is a reasonable first-line treatment for plantar hyperhidrosis. Proper

Recommendations

  • 1.

    Educate the patient to recognize and avoid food triggers and other stimulating factors.

  • 2.

    Although evidence is lacking, topical AlCl may be tried, taking particular care to avoid the eyes.

  • 3.

    Intradermal injection of botulinum toxin is a reasonable option.

Discussion

The treatments for primary craniofacial hyperhidrosis are similar to those for craniofacial hyperhidrosis secondary to Frey syndrome or diabetic neuropathy. Despite the lack of published studies, a majority of the expert panel felt that a trial of

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References (107)

  • J.L Shen et al.

    A new strategy of iontophoresis for hyperhidrosis

    J Am Acad Dermatol

    (1990)
  • B.A Solomon et al.

    Botulinum toxin type A therapy for palmar and digital hyperhidrosis

    J Am Acad Dermatol

    (2000)
  • M Fujita et al.

    Surgical pearl: use of nerve blocks for botulinum toxin treatment of palmar-plantar hyperhidrosis

    J Am Acad Dermatol

    (2001)
  • H Yamamoto et al.

    Needlescopic surgery for palmar hyperhidrosis

    J Thorac Cardiovasc Surg

    (2000)
  • A.D Fox et al.

    The results of thoracoscopic sympathetic trunk transection for palmar hyperhidrosis and sympathetic ganglionectomy for axillary hyperhidrosis

    Eur J Vasc Endovasc Surg

    (1999)
  • B.Y Kim et al.

    Microinvasive video-assisted thoracoscopic sympathicotomy for primary palmar hyperhidrosis

    Am J Surg

    (2001)
  • P.M Goh et al.

    Needlescopic thoracic sympathectomy: treatment for palmar hyperhidrosis

    Ann Thorac Surg

    (2000)
  • I Deblier et al.

    Regarding “Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results.”

    J Vasc Surg

    (1997)
  • D Kopelman et al.

    Upper dorsal thoracoscopic sympathectomy for palmar hyperhidrosis: improved intermediate-term results

    J Vasc Surg

    (1996)
  • R Adar et al.

    Palmar hyperhidrosis and its surgical treatment: a report of 100 cases

    Ann Surg

    (1977)
  • F Herbst et al.

    Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations

    Ann Surg

    (1994)
  • W.D James et al.

    Emotional eccrine sweating. A heritable disorder

    Arch Dermatol

    (1987)
  • K.H Lee et al.

    Video endoscopic sympathectomy for palmar hyperhidrosis

    J Neurosurg

    (1996)
  • T.S Chiou et al.

    Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis

    Br J Surg

    (1999)
  • D Strutton et al.

    Impact of hyperhidrosis on daily life and leisure activities in the US for individuals with auxiliary hyperhidrosis: results from a national consumer panel

    Scientific Poster, Am Acad Dematol Meeting

    (2003)
  • M Amir et al.

    Impairment in quality of life among patients seeking surgery for hyperhidrosis (excessive sweating): preliminary results

    Isr J Psychiatry Relat Sci

    (2000)
  • M Naumann et al.

    Effect of botulinum toxin type A on quality-of-life measures in patients with excessive axillary sweating: a randomized controlled trial

    Br J Dermatol

    (2002)
  • C Swartling et al.

    Botulinum A toxin improves life quality in severe primary focal hyperhidrosis

    Eur J Neurol

    (2001)
  • C.S Cina et al.

    The Illness Intrusiveness Rating Scale: A measure of severity in individuals with hyperhidrosis

    Qual Life Res

    (1999)
  • M Helewa et al.

    Report of the Canadian Hypertension Society Concensus Conference: 1 definitions, evaluation, and classification of hypertensive disorders in pregnancy

    CMAJ

    (1997)
  • E Rey et al.

    Report of the Canadian Hypertension Society Consensus Conference: 3 Pharmacologic treatment of hypertensive disorders in pregnancy

    CMAJ

    (1997)
  • R Altman et al.

    Emotionally induced hyperhidrosis

    Cutis

    (2002)
  • A.K Leung et al.

    Hyperhidrosis

    Int J Dermatol

    (1999)
  • F Ghali et al.

    Idiopathic localized unilateral hyperhidrosis in a child

    Pediatr Dermatol

    (2000)
  • I Bergmann et al.

    Selective degeneration of sudomotor fibers in Ross syndrome and successful treatment of compensatory hyperhidrosis with botulinum toxin

    Muscle Nerve

    (1998)
  • R.G Glogau

    Treatment of palmar hyperhidrosis with botulinum toxin

    Semin Cutan Med Surg

    (2001)
  • M Hund et al.

    Definition of axillary hyperhidrosis by gravimetric assessment

    Arch Dermatol

    (2001)
  • M Naumann et al.

    Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial

    Br Med J

    (2001)
  • R Rompel et al.

    Subcutaneous curettage vs. injection of botulinum toxin A for treatment of axillary hyperhidrosis

    J Eur Acad Dermatol Venereol

    (2001)
  • J.M Swinehart

    Treatment of axillary hyperhidrosis: Combination of the starch-iodine test with the tumescent liposuction technique

    Dermatol Surg

    (2000)
  • C.R.W Rayner et al.

    Axillary hyperhidrosis, 20% aluminium chloride hexahydrate, and surgery

    Br Med J

    (1980)
  • L Glent-Madsen et al.

    Axillary hyperhidrosis. Local treatment with aluminium-chloride hexahydrate 25% in absolute ethanol with and without supplementary treatment with triethanolamine

    Acta Derm Venereol

    (1988)
  • K.T Scholes et al.

    Axillary hyperhidrosis treated with alcoholic solution of aluminium chloride hexahydrate

    Br Med J

    (1978)
  • A Benohanian et al.

    Localized hyperhidrosis treated with aluminum chloride in a salicylic acid gel base

    Int J Dermatol

    (1998)
  • M Heckmann et al.

    Botulinum toxin A for axillary hyperhidrosis (excessive sweating)

    N Engl J Med

    (2001)
  • I.R Odderson

    Long-term quantitative benefits of botulinum toxin type A in the treatment of axillary hyperhidrosis

    Dermatol Surg

    (2002)
  • H Naver et al.

    Palmar and axillary hyperhidrosis treated with botulinum toxin: one-year clinical follow-up

    Eur J Neurol

    (2000)
  • P Schnider et al.

    A randomized, double-blind, placebo-controlled trial of botulinum A toxin for severe axillary hyperhidrosis

    Br J Dermatol

    (1999)
  • M.T Sinclair et al.

    Prospective double blind randomized controlled trial of botulinum toxin A in axillary hyperhidrosis

    Br J Surgery

    (2001)
  • S.R Tan et al.

    Long-term efficacy and quality of life in the treatment of focal hyperhidrosis with botulinum toxin A

    Dermatol Surg

    (2002)
  • Cited by (0)

    Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis: Chair: John Hornberger, MD, MS, Stanford University School of Medicine, Stanford, Calif and Acumen, LLC, Burlingame, Calif; Co-Chair: Kevin Grimes, MD, Stanford University School of Medicine, Stanford, Calif; Samuel S. Ahn, MD, UCLA Medical Center, Los Angeles, Calif; Sten-Magnus Aquilonius, MD, Uppsala University Hospital, Uppsala, Sweden; Daniel Berg, MD, University of Washington Medical Center, Seattle, Wash; Timothy G. Berger, MD, UCSF Medical Center, San Francisco, Calif; Cliff P. Connery, MD, FACS, Columbia University College of Physicians and Surgeons, New York, NY; Jonathan R. Davidson, MD, Duke University Medical Center, Durham, NC; Dee Anna Glaser, MD, St. Louis University Medical Center, St. Louis, Mo; Henning Hamm, MD, University of Würzberg, Würzberg, Germany; Marc Heckmann, MD, Ludwig-Maximilian University, Munich, Germany, Adelaide A. Herbert, MD, University of Texas at Houston Health Science Center, Houston, Tex; Horatio C. Kaufmann, MD, Mount Sinai Medical Center New York, NY; John Koo, MD, UCSF Medical Center, San Francisco, Calif; Louis Kuchnir, MD, PhD, University of Massachusetts, Amherst, Mass; Mark Lebwohl, MD, Mount Sinai School Hospital, New York, NY; Nicholas J. Lowe, MD, Cranley Clinic for Dermatology, London, England; Alan Menter, MD, Texas Dermatology Associates, P.A. Dallas, Tex; Markus Naumann, MD, University of Würzberg, Würzberg, Germany; Hans Naver, MD, PhD, Uppsala University Hospital, Uppsala, Sweden; Ib Odderson, MD, Overlake Hospital and Medical Center, Bellevue, Wash; David M. Pariser, MD, Eastern Virginia Medical School, Norfolk, Va; Frederick A. Pereira, MD, New York Presbyterian Hospital of Queens, New York, NY; Lewis P. Stolman, MD, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ; Carl F. Swartling, MD, Uppsala University Hospital, Uppsala, Sweden; Ada Regina Trinidade de Almeida, MD, Hospital do Servidor Público Municipal São Paulo, São Paulo, Brazil.

    Disclaimer: Adherence to the recommendations in this manuscript will not ensure successful treatment in every situation. Furthermore, these recommendations should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient considering all the circumstances presented by the individual patient.

    Funding sources: Allergan provided financial support for (1) search, synthesis, and analysis of the literature, (2) meeting of the working group to develop this manuscript, and (3) preparation of the manuscript. The sponsor had no role in the analyses or interpretation of the results. All authors had unlimited access to the literature and its analyses. No limitations on publication were imposed, and review before final publication was not required. The authors made final decisions on all aspects of the manuscript.

    Conflicts of interest: (1) Each author received honoraria for attending and participating in the consensus statement development process. (2) With the exception of the Chair and Co-Chair of this committee, committee members are employed or derive income from the practice of medicine involving consultation or use of procedures to manage patients with hyperhidrosis. (3) Dr. Hornberger is Clinical Professor of Medicine at Stanford University School of Medicine, and derives no clinical income.

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