Hyperhidrosis

Overview

Please see CKS hyperhidrosis guidelines (1) or PCDS Guidelines (2)

Patients presenting with hyperhidrosis in primary care should initially be assessed to determine if it is primary (idiopathic) or secondary to an underlying cause.

Generalized hyperhidrosis can be secondary to an underlying cause, whereas focal hyperhidrosis is usually idiopathic. Less commonly, focal hyperhidrosis may also be secondary to a specific cause. See CKS link above for details.

Flushing, as opposed to sweating

Flushing, as opposed to sweating, is likely to be associated with the menopause or rosacea (2). Please see PCDS guidelines on Flushing.

Generalised 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 (2).

If the history is less typical eg symptoms starting in a different age group, night sweats or if the patient is unwell, there could be a secondary cause (2):

• General medical conditions especially Parkinson’s disease, diabetes mellitus (especially hypoglycaemia episodes), thyroid disease. Other possible causes include: cardiovascular disease (heart failure, endocarditis), infections (acute or chronic viral or bacterial infections such as tuberculosis, brucellosis, HIV, and malaria), diabetes insipidus, phaeochromocytoma, acromegaly, carcinoid syndrome, hyperpituitarism, epilepsy, gout. 
• Physiological - anxiety, pregnancy, menopause, obesity.
• Medications  - opiates, oestrogens, cholinesterase inhibitors, antidepressants (venlafaxine, duloxetine, selective serotonin reuptake inhibitors, tricyclic antidepressants, trazodone, and mirtazapine), pilocarpine, propanolol, ciprofloxacin, aciclovir, esomeprazole and goserelin can cause sweating. Sildenafil and apomorphine can cause craniofacial hyperhidrosis.
• Drug misuse or withdrawal — such as alcohol, cocaine and heroin.
• Night sweats - could be due to malignancy (lymphoma,myeloproliferative discorders). 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  

Investigations

If a person has non-specific symptoms and signs, consider the following baseline investigations in order to guide appropriate management (1):

• Full blood count.
• CRP
• Urea and electrolytes.
• Liver function tests.
• HbA1c.
• Thyroid function tests.
• Tests for HIV or tuberculosis, if indicated.
• Blood film for malarial parasites, if indicated.
• 24-hour urine collection for catecholamines, metanephrines (to exclude phaeochromocytoma) and 5-hydroxyindoleacetic acid (to exclude carcinoid tumours).
• Chest X-ray.

Primary Focal Hyperhidrosis

Diagnosis

Suspect a diagnosis of primary focal hyperhidrosis if a person has focal, visible, excessive sweating which:

• Occurs in at least one of the following sites: axillae, palms, soles, or craniofacial region, and
• Has lasted at least 6 months, and
• Has no apparent cause, and
• Has at least two of the following characteristics:
  • Bilateral and relatively symmetrical.
  • Interferes with daily activities.
  • At least one episode per week.
  • Onset before 25 years of age.
  • Positive family history.
  • Localized sweating stops during sleep.

Investigation

Investigations are seldom, if at all, indicated for focal hyperhidrosis (2).

Management

1. Provide advice about lifestyle measures and sources of information and support.

Modification of behaviour to avoid identified triggers where possible (such as crowded rooms, caffeine or spicy food)

For primary axillary hyperhidrosis - use a commercial antiperspirant frequently (as opposed to a deodorant), avoid tight clothing and manmade fabrics, wear white or black (rather than coloured clothing) to minimise signs of sweating, consider use of armpit/sweat shields to absorb excess sweat and protect clothing (obtained on internet or from Hyperhidrosis Support Group)

For primary plantar hyperhidrosis - where possible avoid food and drink triggers if they exacerbate symptoms (including caffeinated products, chocolate, spicy or sour foods, hot foods, alcohol, sweets, food and drinks containing citric acid) 

2.  Recommend that 20% aluminium chloride (Driclor is BNSSG Formulary choice) is used.  This can be prescribed or bought over the counter.

Aluminium chloride should be applied at night, just before sleep to dry skin of the axillae, feet, hands or face (avoiding eyes) and washed off in the morning.  Apply every 1 to 2 days (as tolerated) until condition improves then apply as required (may be up to every 6 weeks).

If skin irritation occurs use topical emollients and soap substitutes, reduce frequency of application or give short course of 1% hydrocortisone cream for up to 2 weeks. Review progress after 1 to 2 months and if successful, treatment can be continued indefinitely.

3.  Consider treating any underlying anxiety which be an exacerbating factor (antidepressants or propranolol can worsen hyperhidrosis and so cognitive behavioural therapy may be preferable)

PCDS also has further advice about management

Referral

Primary Focal Hyperhidrosis

NHS treatment for primary focal hyperhidrosis in secondary care in BNSSG is subject to the Hyperhidrosis Treatment exceptional funding policy. An exceptional funding request for treatment can be made but is now rarely, if ever, funded. 

Secondary Hyperhidrosis

Initial investigations and management should be undertaken in primary care according to suspected cause. Referral should be considered to appropriate specialty to help with management of underlying cause if needed. Before consideration of referral of patients with secondary hyperhidrosis, please consider use of advice and guidance services.

Referral for treatment of hyperhidrosis itself is still subject to the BNSSG Hyperhidrosis Treatment policy.

Resources

(1) Hyperhidrosis | Health topics A to Z | CKS | NICE

(2) Hyperhidrosis (pcds.org.uk)

Patient Resources

Hyperhidrosis Support Group

International Hyperhidrosis Society

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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