Clinical reviewRecognition, diagnosis, and treatment of primary focal hyperhidrosis☆
Section snippets
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.
- a)
- 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
- a)
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
- a)
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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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.