The patient’s unmet needs (PUNs)
A 25-year-old man presents complaining of excessive sweating. He’s suffered the symptom for years, but is finding it increasingly troublesome – he has problems gripping a pen because of it and is embarrassed about shaking hands with colleagues at work. He has no relevant past medical history, but says his sweating is making him increasingly anxious. Having checked out his symptom on the internet, he has discovered that some people are helped by botox injections or surgery and asks whether these might be options for him.
The doctor’s educational needs (DENs)
How common is hyperhidrosis and what are the various types?
Hyperhidrosis is sweating in excess of that required for normal thermoregulation. A US study demonstrated that the prevalence is 2.9% of the population aged over 12 years1 and a third of these patients say the sweating is intolerable and interferes with normal life.
Primary hyperhidrosis is poorly understood, but is likely to be related to over-activity of the sympathetic nerves. It is often focal, affecting the hands, axillae and feet. Secondary hyperhidrosis can be focal or generalised and is related to a variety of conditions including metabolic, endocrine and neurological disorders. But secondary hyperhidrosis is very unusual – there is rarely an underlying cause.
Are there any investigations the GP should consider? Does this depend on the type of hyperhidrosis?
As in this case, most patients with hyperhidrosis are young and otherwise healthy. Rarely, secondary hyperhidrosis is associated with systemic disorders such as hyperthyroidism, but extensive investigation is unnecessary. A general history and examination will suffice for most patients.
What general advice and specific treatment can the GP offer? How much does anxiety contribute to the problem, and are formal anti-anxiety treatments such as cognitive behavioural therapy effective?
You can offer patients some general advice on wearing loose clothing and avoiding any triggers that they can identify. Non-surgical treatments include the use of topical aluminium chloride – which can be bought over the counter – and oral anticholinergic drugs such as oxybutynin, an unlicensed medication. Anticholinergics, though, will only work in around two-thirds of cases and have side-effects – especially dry mouth – that some patients find intolerable.
Anxiety and stress can compound hyperhidrosis, which in turn exacerbates the anxiety, particularly in social situations. Almost half of affected patients report emotional triggers for their symptoms and the association is probably even more common than reported.2
You can consider drug treatments for anxiety, but this should be done on an individual basis. Therapy to alleviate anxiety and stress can also be useful for a small proportion of patients – only refer if it is clear that anxiety is a trigger for the hyperhidrosis, or is making it worse.
What treatment can a dermatologist offer, and when is it appropriate for the GP to make a referral?
Some dermatologists offer iontophoresis for excessive sweating of the hands and feet. This employs an electrical current in water and provides temporary relief rather than a permanent solution – it requires multiple treatments and the results are variable. But iontophoresis is one of the few treatments available for severe sweating of the feet, so patients with intolerable sweating in this area of the body should be referred.
Dermatologists may also recommend intradermal botulinum toxin injections at the site of sweating. This treatment is usually only indicated for axillary hyperhidrosis because it requires multiple injections, which are often too painful for the hands and feet. Botulinum toxin injections are usually successful, but improvement only lasts a few months and the treatment needs to be repeated at regular intervals. It is safe, well tolerated and associated with high levels of patient satisfaction.3
GPs should refer a patient if the condition is having a severe effect on their life – this varies considerably between individual patients depending on what they do for a job and their hobbies. Duration of symptoms is not generally relevant to a referral, since many patients will have suffered in silence for years.
• Primary hyperhidrosis is poorly understood, but is likely to be related to over-activity of the sympathetic nerves.
• Anxiety is a common trigger.
• Studies have shown a prevalence of 2.9%.
• Secondary hyperhidrosis is relatively unusual, but can be associated with a variety of systemic conditions.
• Conservative measures are appropriate in most individuals, which include:
– topical aluminium chloride
– avoidance of triggers
– wearing loose clothing.
• Iontophoresis and intradermal botulinum toxin injections offer temporary solutions for patients with severe sweating of the extremities and axillae respectively.
• Surgery can offer a permanent solution for severe sweating of the hands and axillae. The major side-effect is compensatory sweating elsewhere on the body, which is severe in 1-2% of cases. Careful patient selection and counselling are essential prior to surgery.
When should the GP consider asking for a surgical opinion? What treatments might the surgeon offer and what are the potential complications of these?
The decision about when to refer for a surgical opinion depends very much on the site and severity of hyperhidrosis.
For patients with hyperhidrosis of the hands and axillae, surgery is a permanent solution, while botulinum toxin injection is temporary. GPs will need to have a discussion about this with the patient – some patients would never consider surgery, while others just want a solution and are happy to have an operation.
Some surgeons – usually vascular surgeons with a special interest in hyperhidrosis – offer endoscopic thoracic sympathectomy as a permanent solution for excessive sweating of the hands, axilla and occasionally the face.4 This involves the use of endoscopic techniques to access the thoracic cavity, followed by identification and complete division of the sympathetic nerves responsible for sweating of the upper limb. The procedure is somewhat controversial, but with an experienced surgeon it can offer a dramatic and permanent resolution of symptoms.
Evidence demonstrates a significant improvement in well over 90% of cases of hand sweating and in around 90% of cases of sweating in the axillae, but lower success rates for facial sweating. There is a small but defined risk of recurrence over a period of years. But the main side-effect is compensatory sweating elsewhere on the body – this is quite common, affecting over 50% of patients, but it is not usually severe.
Other rare complications include pneumothorax and Horner’s syndrome. Patients should be counselled carefully before embarking on any surgery.
Mr Ian Loftus is a consultant vascular surgeon with a special interest in the treatment of hyperhidrosis at St George’s Healthcare NHS Trust, London, and reader in vascular science at St George’s University of London
This article was produced in collaboration with the Royal College of Surgeons – a professional body that sets the highest possible standards for surgical practice and training, leading to the delivery of safe and high-quality patient care. The Royal College of Surgeons has expertise, authority and independence, allowing it to act in the best interests of patients and in support of those providing their care. Go to rcseng.ac.uk for more information.
1 Strutton D, Kowalski J, Glaser D and Stang P. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey.J Am Acad Dermatol 2004;51:241-8
2 Herbst F, Plas E, Fugger R and Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs: a critical analysis and long-term results in 480 operations. Ann Surg 1994;220:86-90
3 Doft M, Hardy K and Ascherman J. Treatment of hyperhidrosis with botulinum toxin. Aesthet Surg2012;32:238-44
4 Cerfolio R, De Campos J, Bryant A et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thor Surg 2011;91:1642-8