BMJ  2005;330:1127 (14 May), doi:10.1136/bmj.330.7500.1127

Primary care

10-minute consultation

Hyperhidrosis

¹ Division of Medical Education, Warwick Medical School, University of Warwick, Coventry CV4 7AL Joanna.piercy{at}warwick.ac.uk

Introduction

Useful reading The Whitely Clinic. Sweating.co.uk: the latest in treatment of excessive sweating. www.sweating.co.uk (Suitable for patients.) Bandolier. Botulinum toxin for hyperhidrosis. www.jr2.ox.ac.uk/bandolier/booth/neurol/hyperhid.html

A 26 year old woman presents with excessive sweating, which she says embarrasses her socially and at work. Sometimes her hands literally drip with sweat, making work involving writing difficult. Concerned to conceal her excessive axillary sweating, she is self conscious and particular about her clothing. She asks what help you can give her.

What issues you should cover

Location—Explore and identify the exact locations of the sweating. Possibilities include excessive facial flushing and sweating and axillary, palmar, groin, and plantar hyperhidrosis.

Severity—How disabling is the problem? Explore the effects on her emotional wellbeing and daily social life.

Exclude physiological and psychological causes—Consider other causes, such as hypoglycaemia or hyperthyroidism, although usually these will be obvious. Might there be an anxiety state?

Explanation and advice—Reassure her that sweating is a normal phenomenon. Explain that the evaporation of water from the skin takes heat away from the body and is essential for temperature control and that sweating is controlled by the sympathetic nervous system. It is important that she drink plenty of fluids and consider boosting salt intake, as fluid loss can be substantial.

What you should do

• Be supportive and acknowledge that this is a distressing condition.
  
• Discuss treatment options with her. First line treatments are topical antiperspirants such as aluminium chloride hexahydrate 20% solution. Drug treatment can be of benefit. A low dose of a ß blocker such as propranolol may help. Another possibility is propantheline (Pro-Banthine) in a starting dose of 15 mg three times daily (its side effects are antimuscarinic and include dry mouth and constipation).
  
• Discuss what options might be available from specialists. If anxiety is felt to be the predominant cause, consider referring her to mental health services for cognitive behaviour therapy or biofeedback. Dermatologists may recommend iontophoresis. This involves a small electrical bath in which the hands and feet can be soaked for a number of minutes a week. It works by stopping the sweat glands from producing sweat. Patients can often try out this treatment under hospital supervision to see if it works. They can then buy their own baths for about £250 ($475; 360). This is a very effective treatment for palmar and plantar hyperhidrosis but is ineffective for axillary symptoms.
  
• Botulinum toxin injections seem to be effective, especially for axillary symptoms. The treatment lasts 6-9 months and then needs repeating. It works by inhibiting the release of acetylcholine at the neuromuscular junction and therefore reduces muscle tone and production of sweat. With palmar injections a long term consideration would be the effect on muscle tone.
  
• For very resistant and distressing cases, where all other treatments fail, a surgical procedure called thoracoscopic sympathectomy is available. This is where the sympathetic nerve is cut. In the United Kingdom it is performed mostly by vascular surgeons and is available mainly in the private sector, although some regional centres offer this procedure through the NHS for appropriate cases. The main side effect, which is reasonably common and unwelcome, is compensatory sweating in other areas.
  

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This is part of a series of occasional articles on common problems in primary care

The series is edited by general practitioners Ann McPherson and Deborah Waller (ann.mcpherson{at}dphpc.ox.ac.uk)

The BMJ welcomes contributions from general practitioners to the series

I thank Alison Bedlow, consultant dermatologist at Warwick Hospital, for her helpful correspondence.

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