Hamm_subbed.qxp 19/5/09 12:59 pm Page 84
Hyperhidrosis
Questionnaire can be used to evaluate disease characteristics and of secondary hyperhidrosis. Generalised hyperhidrosis is usually
medical resource utilisation, and to assess the extent of impairment in secondary to internal diseases, including endocrine, metabolic,
occupational, physical, emotional and social functioning.
9
infectious, cardiovascular or malignant conditions, and can also be
caused by certain drugs and poisoning.
7,12
Disturbances of glycose
Frequency of at Least One Episode per Week metabolism, hyperthyroidism and menopause are among the most
A frequency of one episode per week is tremendously understated. frequent problems. Regional types of secondary hyperhidrosis are most
Most sufferers notice increased sweating throughout the day with often caused by neurological diseases. For example, compensatory
repeated exacerbation by individually variable triggers, such as sweating is a well-known complication often occurring after
excitement, stress, heat, exercise and being among people. endoscopic thoracic sympathectomy for PFH, and may occasionally be
more disrupting than the primary disease.
13
Ross syndrome is a rare
Onset Before 25 Years of Age neurological disorder characterised by anhidrosis of expanding parts of
PFH typically starts in childhood or puberty. Remarkably, the age at onset the skin and compensatory hyperhidrosis of the resting areas with
differs significantly in the two most frequent types of PFH. In our maintained sweating.
14
Among focal types, gustatory sweating is
patients, only 7% of axillary patients but 58% of palmar patients reported perhaps the best-known example. Frey syndrome (auriculotemporal
that their excessive sweating began before 12 years of age. Vice versa, syndrome) is a special type of gustatory sweating often occurring after
hyperhidrosis started in only 5% of the palmar patients but in 44% of the surgery or injury of the parotid gland caused by migration of severed
axillary patients above 17 years of age. Almost all patients are affected parasympathetic fibres into post-ganglionic sympathetic fibres to sweat
by the time they reach 25 years of age.
9
These data are in line with the glands and blood vessels in pre-auricular and infra-auricular territories,
mean ages of 19 years for axillary and 13 years for palmar hyperhidrosis resulting in unilateral sweating in the pre-auricular area.
15
found by others.
5
Evaluation of a Patient with Hyperhidrosis
Positive Family History Thanks to the helpful definition elaborated above, exclusion of the
In up to 50% of patients further family members are affected by many secondary types is not required for a positive diagnosis of PFH.
hyperhidrosis, strongly suggesting a genetic background to the A tailor-made history reflecting the pattern of sweating in terms of
condition. Recently, a first gene locus predisposing to primary palmar duration, frequency, volume, areas involved, symmetry, triggers,
hyperhidrosis was assigned to the long arm of chromosome 14 by a sweating during sleep, age at onset, impact on daily activities, family
Japanese group.
10
As a consistent pattern of transmission is lacking in history, medication and symptoms suggestive of systemic disease will
hyperhidrosis families, it is most likely that more than one gene is usually allow secondary types to be distinguished from PFH.
7
On
involved in PFH and that an individually varying genetic predisposition is physical examination, attention should be paid to visible evidence of
determined by an unknown number of susceptibility and severity genes.
9
excessive sweating in characteristic locations and to the detection of
signs suggestive of a secondary cause. In the latter case, the patient
Cessation of Focal Sweating During Sleep should be referred to an internal specialist, a neurologist or a
As recently shown by hourly self-assessment of patients with palmar psychiatrist depending on the suspicion. In a typical case of PFH,
hyperhidrosis, evaluation scores varied considerably depending on time laboratory testing is not required, but quantification of sweat
of day, with lower scores during the mornings and evenings and highest production may be helpful to substantiate the diagnosis and for future
scores between midday and late afternoon. Stress and exercise led to a assessment of therapeutic effects. The iodine starch test is a simple
stronger and longer increase of sweating in patients compared with and useful tool for visualising sweating areas. It is particularly helpful
controls.
11
Typically, PFH patients report that sweating calms down in the axillae prior to therapies such as botulinum toxin injections or
during sleep. Nocturnal diaphoresis rules out the emotional nature of curettage.
1
On the other hand, general hyperhidrosis of recent onset,
sudomotor activity. especially if combined with other constitutional symptoms,
necessitates extensive efforts to identify the underlying cause.
The last three criteria are the most important features distinguishing Secondary hyperhidrosis, particularly if generalised, is usually more
PFH from secondary types of hyperhidrosis. In secondary hyperhidrosis, difficult to treat symptomatically than PFH but, in contrast to the latter,
increased sweating mostly begins in middle or old age, family history is can potentially be cured by elimination of the underlying cause. ■
negative and nocturnal sweating often requiring a change of nightdress
is the rule.
Henning Hamm is a Senior Physician and Vice
Chairman of the Department of Dermatology at the
Secondary Hyperhidrosis
University of Würzburg. His fields of special interest are
The attending physician should be alert to secondary hyperhidrosis if
paediatric dermatology, genodermatology,
dermatological surgery and disorders of the hair, nails
the patient is older or sweating has begun in advanced age, if the
and sweat glands. Since the introduction of botulinum
prediction sites of PFH are not affected or not singularly affected and if
toxin into dermatology, he has been pursuing an
sweating is unilateral and is present or gets worse during the night.
intense co-operation with the neurologist Professor
Markus Naumann in the field of hyperhidrosis.
Tables 2 and 3 summarise the most important of the many causes
1. Hamm H, Naumann MK. In: Truong D, et al., Manual of 6. Adar R, et al., Ann Surg, 1977;186:34–41. 11. Krogstad AL, et al., Br J Dermatol, 2006;154:
Botulinum Toxin Therapy, Cambridge: Cambridge University 7. Hornberger J, et al., J Am Acad Dermatol, 2004;51: 1118–22.
Press, 2009;123–32. 274–86. 12. Haider A, Solish N, CMAJ, 2005;172:69–75.
2. Schlereth T, et al., Dtsch Ärztebl Int, 2009;106:32–7. 8. Glaser DA, et al., Cutis, 2007;79:5–17. 13. Ojimba TA, Cameron AE, Br J Surg, 2004;91:264–9.
3. Hund M, et al., Arch Dermatol, 2002;138:539–41. 9. Hamm H, et al., Dermatology, 2006;212:343–53. 14. Sommer C, et al., Ann Neurol, 2002;52:247–50.
4. Solish N, et al., Dermatol Surg, 2007;33:908–23. 10. Higashimoto I, et al., Am J Med Genet A, 2006;140: 15. Rustemeyer J, et al., J Craniomaxillofac Surg, 2008;
5. Strutton DR, et al., J Am Acad Dermatol, 2004;51:241–8. 567–72. 36:34–7.
84 EUROPEAN DERMATOLOGY
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99