Hyperhidrosis

Signs and Symptoms

Most cases of focal hyperhidrosis are idiopathic, with a possible genetic predisposition. Most commonly affected areas are the axillae, palms and soles. There are no standardised diagnostic criteria for focal hyperhidrosis, and the diagnosis is based on history and physical signs.

History and Examination

• Relevant family history, H/O any co-morbidity, presence of risk factors
• Sufferers do not sweat excessively during sleep. If sweating it present at night, then consideration should be made for further investigation as this would almost certainly be due to a secondary factor.

• Investigations are seldom, if at all, indicated for focal hyperhidrosis
• Generalised hyperhidrosis in a well patient with a classical history of sweating starting in late childhood and improving in middle age is seldom related to an underlying medical condition
• If the history is less typical e.g. symptoms starting in a different age group, night sweats or if the patient is unwell, there could be a secondary cause:
  • General medical conditions especially Parkinson's disease, diabetes mellitus or thyroid disease
  • Medications (new or recent withdrawal) - SSRIs, opiates, oestrogens and GnRH analogues can cause sweating. Sildenafil and apomorphine can cause craniofacial hyperhidrosis
  • Night sweats - could be due to lymphoma. Such a symptom warrants a thorough examination and CXR. If the patient has an associated fever investigate as per PUO (eg SBE, malaria, TB)
  • Rare conditions - if the attacks are associated with pallor, tremor or headaches consider a phaeochromocytoma or insulinoma. Ideally, the relevant investigations need to be done during an attack
• Flushing, as opposed to sweating
  • Flushing, as opposed to sweating, is likely to be associated with the menopause or rosacea
  • If patients are unwell during bouts of blushing, and have associated abdominal pain or diarrhoea, consider the carcinoid syndrome
• The Ross syndrome - extensive anhydrosis leads to islands of compensatory hyperhidrosis. Patients also have Aide's pupils (tonic pupils) and absent tendon reflexes

Formulary, Chapter 13. Skin: Management of hyperhidrosis

Treatments for focal hyperhidrosis are commissioned in the following circumstances:

Topical aluminium Chloride preparations may be prescribed for patients with a hyperhidrosis disease severity score of 2 or greater (sweating is tolerable but sometimes interferes with daily activities).

Aluminium Chloride preparation often causes irritancy leading to discontinuation of treatment. This can be prevented/ treated in some cases by ensuring the skin completely dry before application, and treating irritant dermatitis with a mildly potent topical steroid.

In patients with a Hyperhidrosis Disease Severity Scale score of 3 or more (sweating which is barely tolerable and frequently interferes with daily activities) which has failed to respond to treatment for at least one month with topical aluminium, the following specialist services are commissioned through direct referral to the department of dermatology:

• Systemic oral anticholinergic drugs
• Iontophoresis
• Patients with palmoplantar hyperhidrosis
  • Botulinum toxin is commissioned for use in patients with palmoplantar hyperhidrosis who have not achieved a 50% reduction in sweat production with the above treatments. Botulinum toxin for use in patients with axillary hyperhidrosis in whom the above treatments have proven unsuccessful and who have a resting sweat production per axilla of greater than 50mg in 5 minutes
• Surgical treatment with endoscopic thoracic sympathectomy for severe resistant axillary or palmar hyperhidrosis may be offered with explanation of the risk, benefits and side effects of the procedure.

NHS Devon Treatment of focal hyperhidrosis policy

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Exceptional /Individual Funding Requests (IFR)

Patient Information

MyHealth patient information - Hyperhidrosis

Evidence

North and East Devon formulary - Skin

The Primary Care Dermatology Society.

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NHS Devon.

Publication date: 30 January 2017