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Excessive Sweating and Excessive Body Odor

The primary function of the eccrine sweat glands is to assist in the maintenance of body temperature in response to heat exposure or exercise. Hyperhidrosis may be defined as sweating beyond what is necessary to maintain thermal regulation. It may be primary (idiopathic, essential) or secondary to a number of diseases and prescribed drugs. Hyperhidrosis can be localized or generalized. Regardless of the type or cause of the hyperhidrosis, it is frequently socially embarrassing and occupationally disabling. Excess sweat on the hands may soil paper and art work, and make it virtually impossible to play.

Physiologically, sweating is a function of the sympathetic nervous system. A sweat control center located in the preoptic area and anterior hypothalamus contains neurons that are sensitive to changes in internal temperature.

The causes for generalized hyperhidrosis (Display Box 1) include a number of febrile illnesses, neoplastic and neurologic diseases, metabolic disorders, and drugs. The causes and conditions associated with localized hyperhidrosis include primary palmoplantar hyperhidrosis, unilateral circumscribed hyperhidrosis, hyperhidrosis associated with intrathoracic neoplasms, olfactory hyperhidrosis, gustatory hyperhidrosis, spinal cord injuries.

Hyperhidrosis--The Causes

 
Generalized
Heat, humidity, and exercise
 
Febrile diseases: acute and chronic infections, and neoplasia
 
Metabolic: thyrotoxicosis, diabetes mellitus, hypoglycemia, gout, pheochromocytoma, hyperpituitarism, or menopause
 
Sympathetic discharge: shock and syncope, intense pain, alcohol, and drug withdrawal
 
Neurologic: Riley-Day syndrome, irritative hypothalamic lesions
 
Drugs: propranolol, physostigmine, pilocarpine, tricyclic antidepressants, or venlafaxine
Localized
Heat
 
Olfactory
 
Gustatory: citric acid, coffee, chocolate, peanut butter, and spicy foods
 
Neurologic lesions
 
Primary or essential hyperhidrosis


Primary or essential hyperhidrosis is a disorder that causes hyperhidrosis of the hands, feet, and sometimes the axillae. It is estimated that 0.6% to 1.0% of the population suffers from this problem. Primary hyperhidrosis may be inherited and in contrast to generalized hyperhidrosis usually has its time of onset in adolescence
.

TOPICAL

Aluminum chloride and tanning agents are sometimes effective in the control of localized hyperhidrosis. Although this mechanism has been disputed, aluminum chloride may decrease sweating by mechanically obstructing eccrine sweat gland pores. The atrophy of the secretory cells seen in eccrine sweat glands exposed to aluminum chloride may

Glutaraldehyde, tannic acid, and formaldehyde may be useful to treat palmar and plantar hyperhidrosis, but their tendency to stain the skin and, in the case of formaldehyde solution, its sensitizing potential, limit their usefulness.

SYSTEMIC

For those patients whose hyperhidrosis is related to specific anxiety-producing events such as a speaking engagement, school dance, etc., the use of a drug such as diazepam may have an ameliorating effect. Systemic anticholinergics may be helpful, but unfortunately the dosages required to achieve reduced sweating also result in side effects including xerostomia, mydriasis, cycloplegia, and bowel and bladder dysfunction. Most patients with localized or generalized hyperhidrosis cannot tolerate them for long; however, the anticholinergic oxybutynin (Ditropan, Hoechrt Marion Roussel, Kansas City, MO) has been found to be useful in the relatively rare syndrome of episodic hyperhidrosis with hypothermia. A second anticholinergic, benztropine, was successfully used to treat hyperhidrosis in

AXILLARY HYPERHIDROSIS

Patients with axillary hyperhidrosis who are unresponsive to topical therapy benefit from surgical excision. The area of greatest sweating may be identified by draping a piece of simple tissue paper over the axilla. Sometimes this area is quite small, and simple excision with closure is sufficient to remedy the problem. Patients with moderate to severe

SYMPATHECTOMY

Sympathectomy or upper thoracic (T2) ganglionectomy is frequently offered to patients with severe palmar hyperhidrosis. Lumbar sympathectomy is not usually employed for plantar hyperhidrosis because of the risk of sexual dysfunction. Although the efficacy of this procedure in the treatment of palmar hyperhidrosis is not in doubt, with success rates of 92% to 99%, the complications are significant. Among the complications are compensatory hyperhidrosis (increased sweating in some other area of the body), 24% to 100%; gustatory sweating (sweating usually of the face related to the eating of foods), permanent Horner's syndrome, wound infection, hemothorax.

BOTULINUM TOXIN

Botulinum toxin is a useful therapeutic agent for the treatment of a number of diseases related to muscular dystonia. This potent toxin has proven to be a highly effective remedy for the treatment of conditions previously recalcitrant in the fields of ophthalmology, otorhinolaryngology, pediatrics, gastroenterology, and urology. The cosmetic denervation of muscles of facial expression using botulinum toxin has given dermatologists and plastic surgeons a new weapon.

IONTOPHORESIS

By far, the simplest, safest, and most cost-effective remedy for palmar or plantar hyperhidrosis is iontophoresis, which is defined as the introduction of an ionized substance through intact skin by the application of a direct current. In 1936, Ichihashi used various solutions of atropine, histamine, and formaldehyde, and by iontophoresis demonstrated that sweating of the palms could be reduced.