Hyperhidrosis

DIAGNOSIS:

Hyperhidrosis is excessive sweating that occur under normal conditions. This is a common situation. The diagnosis is easy to establish clinically. The main difficulty is the etiologic diagnosis to avoid missing a secondary cause. Thus, a primary hyperhidrosis is never (until proven otherwise) night, there is no deterioration of general condition, no fever, no blood pressure lability. Physiology is recalled in Box 1.

Before a consultant for a person sweating, you have to ask four questions:

– Is generalized or localized?

– Is it isolated or associated with other symptoms?

– Is the trouble new or old?

– There is a family history (found in palmoplantar forms in 25% of cases)?

We distinguish generalized hyperhidrosis, localized hyperhidrosis hyperhidrosis and night (night sweats).The latter are often an alarm signal to a potentially serious general pathology.

Box 1. sweating Physiology
Sweating is under the control of the autonomic nervous system with two basic components: thermorégulante sweating and emotional sweating.
The thermorégulante sweating is under thalamic control, it is both day and night.
Emotional sweating is under cortical control and is diurnal.
The mediator in action in the sudomotor nerves is acetylcholine which fixed on muscarinic receptors.
The sweating is primarily the role of the eccrine glands.
The eccrine glands are distributed over the entire body, but unevenly, predominant on the front in mid-thoracic area, back and in the palmoplantar areas.
They secrete sweat normally odorless.
This system is unique to man and the horse.
Meanwhile, there are apocrine sweat glands located in the armpits, in the anogenital region and areola.Sweat excreted is degraded by the skin fl ora and becomes fragrant. This system exists in all mammals and plays an important role in sexuality.

ETIOLOGY:

Generalized hyperhidrosis:

The causes are listed in Table I.

Isolated hyperhidrosis those associating one distinguishes other symptoms.

Generalized hyperhidrosis isolated:

Medications:

Many drugs have been implicated: opioids, serotonin reuptake inhibitors, NSAIDs, pilocarpine, progestogens, tamoxifen, derivatives of vitamin A, interferons, inhibitors of the proton pump, some herbal remedies such as borage, etc.

Toxic:

Alcohol and drugs can cause sweating both at the time of intoxication during periods of withdrawal.

Stress:

Stress is a cause of localized but sometimes generalized sweating.

Obesity:

Obesity is often sweating factor.

No cause found:

A number of generalized hyperhidrosis which we do not find the explanation are called idiopathic.

Generalized hyperhidrosis associated with other symptoms:

Infectious context:

Sweat often accompanies the disease and thus may be observed in all infectious diseases. It can be day or night predominance.

Sometimes sweating is offset relative to fever spikes. This is classic in tuberculosis, brucellosis, endocarditis Osler.

It can persist long after recovery from infection.

Systemic medical settings:

The sweating is a symptom of the following conditions:

– Menopause: it supports hot flashes;

– Diabetes (if neuropathy), and hypoglycemia: it accompanies malaise, tremor, hunger for sensation;

– Thyrotoxicosis hyperthyroidism;

– Congestive heart failure;

– Variant angina: with the possibility of nocturnal episodes;

– Pheochromocytoma: it is part of the triad inappropriate sweating, tachycardia and throbbing headache at the time of blood pressure surges;

– Dumping syndrome: there may be sweating, flushing, palpitations, abdominal pain, diarrhea. The frequency and severity of these symptoms are variable, the diagnosis based on the combination of several of them and repetition of crises. These may occur within the hour following the meal or two hours after.

This condition is often the result of stomach surgery. Treatment is based solely on a diet with splitting meals that must be small and low in sugars.

Onco-hematological causes:

The sweating was found in the following cases:

– Certain lymphomas with night sweating.

It is sometimes the only sign of the classic triad fever, night sweats and weight loss of Hodgkin’s disease;

– Carcinoid tumors.

Neurological:

The sweating was found in the following cases:

– The “thermostat” of regulation found in the hypothalamus, the injuries to this area can cause hyperhidrosis: cerebrovascular accident (stroke), tumors, surgery scars;

– In case of spinal injuries above D6, there are profuse sweating of the upper body that can occur many years after the initial accident;

– It can be found in orphan diseases such as Riley-Day syndrome, the syndrome congenital insensitivity to pain, and motor peripheral neuropathy

with autonomic dysfunction;

– There is sometimes a sequel, type of sweating of the trunk after thoracic sympathectomy performed to treat palmar hyperhidrosis.

Localized hyperhidrosis:

Localized hyperhidrosis is found mainly in the armpits, feet, hands and face.

Emotional hyperhidrosis:

Emotional hyperhidrosis is undoubtedly the most common of all. It is observed preferably in very impressionable and obese subjects. Sweat constantly or pearl at the slightest effort or any emotion. This is from the eccrine sweat glands, thus odorless, but in large shapes, there may be a maceration of skin folds, source of unpleasant odors. On the feet, there is very often a mycotic infection.

Unilateral chest hyperhidrosis:

Chest tumors (lung cancer, mesothelioma) can compress the sympathetic fibers and lead to spontaneous sweating, profuse. Most often this symptom is not isolated. There is then: pain, respiratory disorders, poor general condition.

Idiopathic unilateral circumscribed hyperhidrosis:

These episodes of profuse sweating, isolated, brutal, in a limited area of ​​a few cm 2, with no clinical signs in a healthy subject. We do not know the cause.

Gustatory hyperhidrosis:

The gustatory sweating hyperhidrosis is more or less predominant in the forehead, nose and lips when taking hot or spicy foods. It may be accompanied by salivation, tears, nasal flow of flush. It is sometimes unilateral, then the sequela of parotid lesion.

Other causes:

Note in more rare:

– Harlequin syndrome, affecting a hemifacial;

– Hyperhidrosis lacrimal, supraorbital, associated with Horner syndrome.

Nocturnal hyperhidrosis:

The problem is different from that of sweating although there common etiologies.

Night sweats are considered signifi cant if they force the patient to change.

The list of possible diagnoses is relatively long, however, it must adopt a rigorous approach to eliminate the most serious diseases. We must seek to interrogate the notion of fever, cough, weight loss, a flush, diarrhea, contamination risk factors for HIV, endocarditis, diabetes.

Physical examination should obviously look for lymph nodes, a higher or lower vena cava syndrome, splenomegaly, a heart murmur, exophthalmos, skin of endocarditis.

The minimum balance must include a standard biology with sedimentation rate (ESR) and C-reactive protein, a chest radiograph, abdominal ultrasound, HIV status can be made immediately if the context is evocative.

Etiology:

The causes may be infectious in nature, drug or hormonal.

Infectious etiology:

Among the infectious etiologies, we must especially mention tuberculosis, brucellosis, HIV, infectious mononucleosis, endocarditis, pulmonary abscess.

In a patient blown AIDS we must think to opportunistic infections such as atypical mycobacteria of the Mycobacterium avium complex (CD4 <100 / mm3), but also tuberculosis, cytomegalovirus.

Tumor pathologies involved are mainly lymphomas, particularly Hodgkin’s disease, but also solid tumors may be liable as kidney cancer.

Endocrine disorders that may be involved are hyperthyroidism, pheochromocytoma and carcinoid tumors.

In diabetic patients, the occurrence of night sweats search is primarily nocturnal hypoglycemia.

In elderly patients, you have to mention, in addition to raised etiologies, GCA.

Drug-induced:

The drugs reported as night sweats makers are numerous: the class of neuroleptics phenothiazines (chlorpromazine), interferon-α, some antiretroviral (zalcitabine, indinavir, saquinavir, efavirenz), antidepressants and tamoxifen.

The diagnosis is more evident with some medicines used in a timely manner as rituximab anti-CD20 (MabtheraR) or when one finds the antipyretic outlet.

In a similar vein, we must think of alcoholism and addiction to heroin. However, it is also predisposing land for many etiologies already mentioned, we must be vigilant.

Various etiologies:

Some diseases appear to be sometimes night sweats officials such as the sleep apnea syndrome, gastroesophageal reflux disease, Takayasu’s disease, variant angina.

Hormonal causes:

It should be noted special circumstances, the mechanism would be hormonal such as menopause and pregnancy, obviously such causes should not be held until at least the balance sheet.

TREATMENT:

When there is a curable etiology, treatment of the cause solve the problem. In some cases, psychotherapy, relaxation, acupuncture are tried.

Treatment with systemic:

The general treatment is not routinely used because, to be effective, high doses are often needed and cause little tolerable side effects.

Anticholinergic:

They are trying after failure of other treatment because they have really too many side effects: dry mouth, tachycardia, constipation, worsening of glaucoma, urinary retention, etc. In this context, oxybutynin (Ditropan) have been tried (Authorisation out on the market [AMM]).

Alpha:

Alpha-blockers affect the central sympathetic nervous system. Clonidine (Dixarit®) has shown efficacy intravenously.As per os, it must be taken in large doses, which makes it almost impossible usage.

Calcium channel blockers:

Calcium channel blockers give fairly good results, such as diltiazem (Tildiem®) at a dosage of 30 mg / 4x / d.

Psychotropic:

Hyperhidrosis frequently occurring on land anxiety, anxiolytics have been tried.

However, they often induce a partial remission, losing their effectiveness and risk of addiction. Some success has been noted with hydroxyzine (Atarax®) which has the advantage of having a tranquilizer and anticholinergic effect.Beta-blockers in the forms related to emotional stress can be interesting.

The new inhibitor antidepressants serotonin reuptake have anticholinergic action without too many side effects and an indication in chronic anxiety. They may therefore be useful in the future.

A test with paroxetine (Deroxat®) was reported.

Finally, topiramate (Epitomax®) used as anticonvulsant and migraine can sometimes be effective, but it has not the marketing authorization for this indication.

Treatment with topical:

Antiperspirants:

Most are made from alumina salts associated or not with other metal salts They work by clogging the pores of the sweat glands. They should initially be applied daily, and maintenance therapy is needed because of a twice a week.They are more effective application under occlusion (gloves hands tight cap for the scalp). However, they face a high risk of local irritation. This is most often Cosmetology and drugstore products (eg Driclor®, Etiaxil®, PM®). They are primarily intended for axillary hyperhidrosis and is in the form of aerosols, sprays, sticks, beads, powders or creams.

Iontophoresis:

Iontophoresis is used mainly for palmoplantar hyperhidrosis.

It is based on the principle of electrolysis. In a tank of water, passing an electric current of low amperage between two electrodes.

The patient puts his hands or feet in the tub for a session of about 20 minutes. In the early sessions are weekly or plurihebdomadaires then, in the maintenance phase, monthly or less. The incidents are very rare type burns. The results are excellent (around 80%).

The system can be purchased in pharmacies or specialized medical store.

There are cons-indications: child, pregnant woman or person carrying a pacemaker or an IUD.

Botulinum toxin (Botox®):

Botulinum toxin acts by blocking the release of acetylcholine in the synapses of the neuromuscular junction. In France, the marketing authorization is granted for axillary hyperhidrosis.

It is injected into the dermis in several separate points of one to two centimeters with a hypodermic needle. The maximum dose is 50 units per axilla. The injection is painful and should be done under local anesthesia. The effectiveness manifest quickly (one week on average) and lasts about six months.

The injections can be repeated after a period of four months.

Handling should be done by a trained physician.

It seems less interesting for palmoplantar areas where there may be side effects of pain type and muscle weakness.

Surgery:

This is the thoracic sympathectomy (destruction of the sympathetic ganglion) and sympathotomie (destruction only fibers from the sympathetic ganglion).

Sympathectomy has long been used in the axillary and palmar excessive sweating.

It is performed endoscopically. The results are excellent in the majority of subjects. However, there are side effects reaction sweating in other areas (chest, legs). In a few cases, it was reported pneumothorax, hemothorax, or syndrome Horner, usually transient.

In our view, it is desirable to exhaust local resources and drug before considering surgery.