Hyperhidrosis, or excessive sweating, is a common skin condition which can lead to psychological distress and negative self-view. Primary hyperhidrosis is defined as excessive sweating of certain body areas without psychological reasons. Hyperhidrotic patients report a high rate of psychological strain and impaired quality of life due to the social and psychological implications of primary hyperhidrosis. This article will review a 2014 study which aims to investigate the relationship between hyperhidrosis and different psychological/physiological aspects of chronic stress as a cofactor for the etiology of depression. This study compares 40 hyperhidrotic subjects to 40 age- and sex-matched healthy control subjects. Tools used in this study to measure responses are the Tier Inventory of Chronic Stress (TICS), the Beck Depression Inventory (BDI-II) and the Screening for Somatoform Disorders (SOMS-2). The cortisol awakening response of each patient was also analyzed as a psychological stress correlate. Below is a summary of the study results:
Hyperhidrosis Impact Questionnaire
47.5% of subjects reported the onset of their hyperhidrosis at an age between 12-17 years. 35% were over 17 years old, 10% were between 6-11 years old, and 7.5% were below the age of 6 at onset of disease. The body regions most frequently affected were the armpits (50%), palms (25%), and the face (17.5%).
Tier Inventory of Chronic Stress (TICS)
The hyperhidrotic group of patients showed significantly higher values for “lack of social recognition”. 4 other scales, uncorrected, showed “social overload”, “excessive demands from work”, and “chronic worrying” reflected a trend towards more chronic stress in the hyperhidrotic patients.
Beck Depression Inventory
As measured by the beck depression inventory, 24 out of 40 hyperhidrotic patients (60%) reached total sum scores equal or greater than 9, which represents the screening’s cut-off for an indication of depression. In comparison, 4 out of 40 (10%) of healthy control subjects provided a sum of 9 or greater. Overall, the hyperhidrosis showed a significantly increased risk and prevalence of depression. Comparing only axillary hyperhidrotics to the control group produces even larger differences: without correction, axillary hyperhidrotics would have a higher BDI-II sum score than other hyperhidrotics, illustrating that axillary hyperhidrosis can often be the most psychologically debilitating location.
Screening for Somatoform Disorders
No significant differences found.
Cortisol Levels
No significant differences found.
Resources:
1) Gross KM, Schote AB, Schneider KK, Schulz A, Meyer J. Elevated social stress levels and depressive symptoms in primary hyperhidrosis. PLoS One. 2014;9(3):e92412. Published 2014 Mar 19. doi:10.1371/journal.pone.0092412
Hyperhidrosis is a condition marked by excessive sweating, caused by the overstimulation of cholinergic receptors on eccrine glands. This condition results in perspiration that exceeds the body's needs for regulating temperature. Eccrine glands, which are densely located in the armpits, palms, soles, and face, are most often linked with hyperhidrosis. Research indicates that about 3% of people in the United States are affected by this disorder. The impact of hyperhidrosis extends beyond physical symptoms, leading to significant emotional, psychological, social, and professional challenges.
Primary hyperhidrosis typically begins in childhood, affecting between 0.6% and 1% of the population. A hereditary form with autosomal dominant inheritance has been identified, with some families showing a link to an abnormality on chromosome 14q. The criteria for diagnosing hyperhidrosis include excessive sweating lasting at least six months without a clear cause, and meeting at least two of the following conditions: daily activity impairment, bilateral and relatively symmetrical sweating at least once per week, onset before the age of 25, cessation of focal sweating during sleep, or a positive family history. Secondary hyperhidrosis, on the other hand, can be triggered by drugs (such as sertraline), toxins (like acrylamide), systemic illnesses (including endocrine and metabolic disorders, neoplasms, spinal cord lesions), or congenital conditions such as familial dysautonomia (Riley-Day syndrome).
The pathophysiology of hyperhidrosis involves the overactivity of eccrine sweat glands, which are regulated by the sympathetic nervous system through cholinergic fibers. These fibers transmit impulses as a physiological response to control core body temperature during physical exertion or psychological stress. The hypothalamus, acting as the thermoregulatory center, oversees this sympathetic innervation to the sweat glands. When muscarinic receptors are stimulated by cholinergic activity, sweating is induced. In hyperhidrosis, there is excessive activation of the sympathetic nervous system, leading to an abnormal release of acetylcholine from nerve endings. This overproduction of acetylcholine causes the body to produce more sweat than necessary for cooling. It is believed that this condition may stem from a malfunctioning negative feedback mechanism in the hypothalamus, resulting in disproportionate sweating. This pathological response can also be triggered by medications that increase acetylcholine release or by systemic medical conditions that enhance sympathetic nervous system activity.
The treatment options for hyperhidrosis include a range of topical and systemic therapies. First-line therapy often involves the use of over-the-counter aluminum chloride hexahydrate 20%, applied for 3 to 4 nights. Another option is topical glycopyrronium tosylate, available as a pre moistened cloth containing 2.4% glycopyrronium solution, which has been approved for treating excessive sweating. These agents work by denaturing keratin, thereby blocking the pores of the sweat glands and reducing perspiration.
For patients who do not respond to topical treatments or exhibit more generalized symptoms, oral anticholinergic medications can be considered. These include oxybutynin, administered at doses of 5 mg to 10 mg daily, or topical glycopyrrolate at concentrations of 0.5% to 2.0%. While effective, these anticholinergic medications can cause side effects such as dry eyes, dry mouth, urinary retention, and constipation.
If both topical and oral drug therapies are ineffective, other treatment modalities may be explored. Iontophoresis, performed 2 to 3 times weekly, and botulinum toxin A injections, administered every 3 to 4 weeks, are additional options for managing hyperhidrosis. These treatments offer alternative strategies for patients seeking relief from excessive sweating. Botulinum toxin is a highly effective treatment for hyperhidrosis, though it is costly and necessitates repeated sessions. Some specialists advise combining botulinum toxin with lidocaine for axillary injections to enhance comfort and effectiveness. The mechanism of action for botulinum toxin A involves cleaving the SNAP-25 protein, which disrupts the presynaptic fusion and binding of acetylcholine vesicles to the nerve terminal, thereby inhibiting the release of acetylcholine. This makes it an optimal choice for patients who have not achieved adequate results with topical antiperspirants and oral anticholinergics.
Hyperhidrosis is a condition that extends beyond physical discomfort, significantly impacting various aspects of a person's life. The excessive sweating associated with hyperhidrosis can lead to social embarrassment, emotional and psychological distress, and can even cause disabilities related to work or school. Despite the availability of treatments such as topical agents, oral medications, iontophoresis, and botulinum toxin injections, managing hyperhidrosis effectively requires a tailored approach to address the unique needs of each patient. By understanding the profound effects of this condition and exploring the range of treatment options, healthcare providers can better support individuals in achieving relief and improving their quality of life.
Brackenrich, J. (2022, October 3). Hyperhidrosis. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK459227/#:~:text=Hyperhidrosis%20is%20a%20disorder%20of%20excessive%20sweating%20due,the%20body%20uses%20for%20homeostatic%20temperature%20regulation.%20
Lakraj, A.-A. D., Moghimi, N., & Jabbari, B. (2013, April 23). Hyperhidrosis: Anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705293/
Mayo Foundation for Medical Education and Research. (2022, September 16). Hyperhidrosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hyperhidrosis/diagnosis-treatment/drc-20367173