Quality of Life with Excessive Sweating in Hyperhidrosis

Sweating is the hot, sticky feeling that most often comes with warmer temperatures and high activity. Yet, for some of us, it can be a daily condition regardless of location or activity and can be something we suffer from silently. This excessive sweating, called hyperhidrosis, is more than the average level of sweat our bodies require to maintain proper body temperatures.^[1] 

The Science of Sweating and How it Changes in Hyperhidrosis 

The human body contains approximately 4 million sweat glands, and their primary function is to produce sweat to regulate body temperature.^[2] In studies examining the sweat glands, researchers found no difference in structure or number of sweat glands in patients with hyperhidrosis compared to patients without hyperhidrosis.^[2-4] While the exact cause of the excessive levels of sweating is still under research, what we know is that sweat is stimulated by both emotional triggers as well as sensory triggers like temperature. Sweat glands are divided into two main types: eccrine and apocrine. Eccrine sweat glands are located generally throughout the whole body and help keep the body cool.^[5] The neurotransmitter acetylcholine stimulates the eccrine sweat glands.^[6] Apocrine sweat glands are located in areas like the armpits and around the anus; they begin functioning during puberty and are activated during stress and sexual excitement.^[7] Stress stimulates both eccrine and apocrine sweat glands.^[6] This part of the normal nervous system is associated in the “fight-or-flight” response. For example, when confronted with a frightening situation such as a bear chasing you, your body produces stress hormones like adrenaline. It reacts by dilating your pupils and increasing your heart rate, breathing, and sweating. When the stress of an emotional trigger and external temperature trigger are combined, the production of sweat in the body increases as well.^[8] However, in hyperhidrosis, the body inappropriately excites the sweat glands, causing too much sweat production than what is usual.

Sweating Can Interfere with Your Life

For those suffering from hyperhidrosis, it can permeate through all facets of life. In a morning workout, you might find yourself hurrying to the cleaning wipes after your session creates a small waterfall on the machines. You gripe in frustration when the touch ID on your cell phone doesn’t recognize your fingerprint because of sweat. Your wardrobe is filled with black clothing; it hides the inevitable sweat but at least your clothes match. In your first meeting of the day, you purposefully wipe your hands on your pants prior to a handshake. Hopefully, your colleague won’t notice the wetness that will form upon immediate contact. Maybe next time you can explain that you have a cold as a reason for why you don’t want to shake hands. At least your black clothing hid your sweat dripping from your arms and back. You type your morning report on the warm keys of your laptop, consciously swiping sweat away from the keyboard; hopefully, it doesn’t break the electric circuitry. Taking a break from electronics, you decide to write your ideas on paper. Be sure to select the proper pen with ink that doesn’t bleed easily. The paper tears slightly as the sweat soaks through the page. Your colleague asks why your shoes are wet even though the weather is sunny outside. With a flush, you state that you stepped in a puddle on the way to work, avoiding all conversation of sweat. Each day, while these small problems are a mere drop in the bucket, you feel self-conscious about your sweat and you avoid sweat-inducing activities. The stress and anxiety induced by sweating are directly related to the intensity of the sweating as well as a decreased sense of self-confidence.^[9-12]  

Hyperhidrosis is Not Rare

Hyperhidrosis affects the daily aspects of life and causes embarrassment. An estimated 7.8 million individuals (2.3% of the United States population) suffer from excessive sweating.^[13] In most cases in the United States, only one-third of individuals afflicted with hyperhidrosis even mention it to their health care providers, usually because most are not aware of the potential treatment options even though the excessive sweating interferes with their daily lives.^[13] Both men and women can be affected, usually between the age of 25 to 64 years. Often individuals with hyperhidrosis have a family history of sweat, with initial start of symptoms at a young age.^[14] Usually, the sweating begins during childhood, but treatment is not usually sought by patients until adulthood, which may lead to underestimation of how common it is among children.^[13,14] 

The Diagnosis of Hyperhidrosis

The first step in the diagnosis of hyperhidrosis is to determine the location of the sweating: it can either be locally in one area or diffuse, across the body.^[15] If the sweating is localized to separate areas such as the hands, armpits, or feet, it is usually idiopathic, meaning doctors do not know the cause.^[1,15] Hyperhidrosis in these areas is most often triggered by emotion or an external source.^[16] If the excessive sweating is dispersed across the entire body, it is also usually idiopathic as well. However, in rare cases of full body excessive sweating, it can be due to an illness, such as a neurologic condition.^[17]  

Treatment of Hyperhidrosis

Treatment options can range from skin surface creams to oral medications to surgical interventions. Many of the medications are used off-label from FDA indications and at the discretion of a qualified physician. Many of these treatments, such as an injection with botulinum toxin, have proven improvements in social anxiety and depression for patients with hyperhidrosis.^[18-20] 

• Ammonium Chloride – a common ingredient in over-the-counter antiperspirant products in a percentage of 1-2% and available in prescription form of 20% concentration.^[21]
• Glycopyrrolate – available as a cream or as a pill; this treatment needs a prescription from a practitioner.^[15]
• Oxybutynin – available as a pill; this treatment requires a prescription from a licensed practitioner.  
• Iontophoresis – delivers a controlled electrical current through water-soaked pads in areas of sweating. While the exact mechanism of this treatment is not well known, the small electric pulses have side effects of discomfort and itching.^[22]
• Botulinum Toxin – used in injections often into the armpits, hands, and feet to help reduce the nerve communication to the sweat glands.^[23] Injections into the hands and feet can sometimes cause muscle weakness. 
• Local Excision – the surgical removal of sweat glands offers more of a permanent solution to excessive sweating.^[24] While this does offer a long-lasting solution to hyperhidrosis, this treatment is usually completed only after other treatments have failed. Additionally, this treatment option has not been extensively studied.^[25]
• Sympathetic Denervation – surgical treatment of the internal sympathetic nerves that offers a permanent solution to upper body hyperhidrosis but has the potential risks and problems associated with surgery.^[26]