Dr Ros Jabar outlines the causes of excessive perspiration along with suitable treatment options
Most people have had sweaty palms at some point, usually when they’re nervous, but the vast majority of those do not have a medical condition. However, there are some who do. Hyperhidrosis is a relatively common condition that can cause a person’s palms, as well as their feet, armpits and other parts of their body, to sweat excessively, and it’s not always related to exercise.1 Patients with hyperhidrosis can experience heavy sweating to the point that it soaks through clothes and drips off their hands. This can understandably become a cause of social anxiety and embarrassment, as well as disrupting a patient’s day-to-day life to the extent that they feel they need to seek treatment.1
For all mammals, sweating is a response that fulfils a number of functions. It helps with thermal regulation and offers an equilibrium for our pre-historic instinct to self-protect and survive. Sweating can also be an indicator of a patient’s psychological state. As humans, we possess three different types of sweat glands (eccrine, apocrine and apoeccrine), which all contribute to these regulations and functions.2
Eccrine glands are found throughout the body and are in abundance on the hands and feet. While physiological sweating of the face, neck, armpits and back is an important part of thermoregulation, the eccrine glands on the hands and feet are stimulated by the nervous system, which is why it’s common to get sweaty palms when nervous.3
Humans have between two and four million eccrine sweat glands across their bodies, which can be found on hairy (non-glabrous) skin such as the face and limbs, and smooth (glabrous) skin as found on the palms and soles of the feet. Eccrine gland density differs across the surface area of the body, with the highest gland densities found on the palms and soles.3 The density of the eccrine glands on non-glabrous skin is between two and five times greater than it is on glabrous skin.3
Eccrine sweat glands primarily produce sweat in response to an increase in body temperature, but skin temperature and increased blood flow can also stimulate the glands.3 The rate at which people sweat is down to the density of their active sweat glands, as well as the rate of secretion per gland.3
As medical professionals, we look to investigate when these typical sweat responses are not a reaction to heat, and are instead a response to a patient’s tolerance being full and their usual coping mechanisms for stress and self-soothing are ineffective. When diagnosing hyperhidrosis, I look for ‘emotional sweating’ which is not caused by heat but by mental stress, deep respiration and local tactile stimulation including the warming, drying and rubbing of the soles of the feet. This emotional sweating can create challenges for patients and make slips more likely, even when doing gentle, everyday holding and stepping. In my consultations, I will ask the patient questions such as when they notice the sweating is worse and if they are prone to any other sweaty areas.
There are two types of hyperhidrosis:1,3,4
1. Primary hyperhidrosis: This is caused by an overactivity of the sympathetic nervous system which leads to the narrowing of arteries and the excessive stimulation of eccrine sweat glands, causing excessive sweat production. It commonly occurs in the hands (palmar hyperhidrosis), feet (plantar hyperhidrosis) and armpits (axillary hyperhidrosis). There isn’t a known medical cause, but it’s thought to have a genetic link, with 40% of patients having a family member with the condition.5
2. Secondary hyperhidrosis: This condition is caused by an underlying medical condition such as diabetes, thyroid issues, some cancers (leukaemia, Hodgkin’s lymphomas, liver cancers for example), menopause, infections or nervous system disorders. It can also be a side effect of certain medications, including antidepressants, pain relievers and some hormonal and diabetes medication. Secondary hyperhidrosis can cause sweating all over the body, although it’s typically worse in the palms, feet and underarms due to the relatively high concentration of sweat glands in these areas.
The psychological and emotional impact of excessive sweating can damage a patient’s confidence and have a significant impact on their day-to-day life. The condition can cause social, psychological and occupational problems, with many hyperhidrosis sufferers reporting negative impacts on their social life, sense of wellbeing and emotional and mental health.5,6 A total of 5% of sufferers take antidepressants or anti-anxiety medications due to their sweating.5,6
Although hyperhidrosis can have a detrimental impact on sufferers’ lives, excessive sweating from eccrine glands is not a source of odour. Eccrine glands secrete a clear, odourless fluid. The ‘body odour’ we associate with sweating is produced by another type of sweat gland called the apocrine gland.6 These glands are found in the armpits and genital region, and produce a thick fluid which produces a potent odour when it comes into contact with bacteria on the skin’s surface.6
There are a number of non-surgical treatment options for hyperhidrosis, including:7
There are also several methods of surgically treating hyperhidrosis by cutting, clipping or removing the affected nerves. Although this can be effective for the treatment of palmar hyperhidrosis, improvement in plantar and axillary sweating is less consistent.
A 14-year-old boy was referred to me by his mother and school teacher. The patient had to change his cotton gloves six times a day just to be able to hold his pen at school. He also didn’t want to hold hands with anyone or play any ball games or sports, and sadly became a withdrawn teenager. As the patient was under 18, we could only provide treatment with a legal guardian present, and as the procedure was deemed medical, it could only be performed in a registered establishment. His treatment therefore occurred at the University Hospital of Wales Medicentre which is registered with Healthcare Inspectorate Wales.
If treating hyperhidrosis in other regions of the UK, the establishment should be registered with the Care Quality Commission, Health Improvement Scotland or The Regulation and Quality Improvement Authority in Ireland. The first stage of the treatment was a full and thorough consultation with both the patient and a parent present due to his age. During the consultation, I learnt that a toxin had previously been administered by another medical practice, but the patient had found this traumatic due to too many healthcare professionals being in the room, as well as the use of diabetic needles causing pain. He was reluctant to try this treatment again, so we decided to explore other options.
Throughout the consultation, it was evident that the patient suffered from palmar hyperhidrosis, which was most likely to be primary hyperhidrosis. His mental health had been affected and his confidence was low. His academic progress had also been negatively impacted. Despite the patient’s previous experience with a toxin, I decided this was the most appropriate treatment in this case. Although the patient found the treatment painful, he had noticed a reduction in sweat and his mother agreed. However, I wanted to deliver the treatment in a much calmer and more comfortable environment to reduce the patient’s anxiety and discomfort.
I reduced the number of staff present in the room, played music of the patient’s choosing and his parent waited in the waiting room at the patient’s request. I explained the process to the patient in full before the treatment began, and made it clear to him that he could leave and change his mind at any point. I chose not to perform the starch test so as not to put the patient through any more unnecessary stress. However, I would usually perform this to identify moisture released from the sweat glands/skin. A thin layer of iodine tincture is applied to the area until it dries. After, a thin layer of starch powder is applied, showing a pale brown colour. When moisture/sweat is produced, the starch and iodine mix to form a polyiodide that has a blue/purple appearance, indicating the prescence of moisture/sweat.8
I applied topical anaesthesia and then drew a grid on the palm of the patient’s hand to help deliver the toxin in equally spaced 1-2cm aliquots of 2-3 units.8 We also did the same on the medial and lateral aspects of his fingers and thumbs (Figure 1). I used high gauge 32 needles to apply the treatment and used multiple syringes to deliver the toxin to keep the needles sharp and reduce any discomfort. The toxin was delivered just below the skin’s surface, leaving small blebs. I delivered 50 units of toxin to each hand, and the treatment was completed in no more than 10 minutes. The speed and precision of the treatment were central to the patient’s comfort and confidence.
There are potential side effects to any treatment including pain, bleeding, bruising and infection, all related to the needles and breaking of the skin, but this patient did not experience any side effects. The aftercare provided to the patient included avoiding activities involving the hands for the next four to six hours, avoiding hot baths/showers, avoiding other hand treatments and refraining from moisturising or massaging the hands.
For nine months of the year, the patient’s palms were completely dry. We would see him for a follow-up after this time. He has since gone on to complete his GCSEs and A-Levels and is now studying engineering at university. His confidence has increased exponentially – he is excelling at his studies, socialising assuredly and is in a healthy relationship.
Excessive hand and feet perspiration is usually the result of a condition known as hyperhidrosis. Although it’s not clear why hyperhidrosis develops, it’s thought to have a genetic element (primary hyperhidrosis), but could also be caused by a medical condition or by taking certain medications (secondary hyperhidrosis). Patients with palmar (hand) or plantar (feet) hyperhidrosis should see a healthcare provider if the sweating disrupts their daily routine or causes emotional distress or social withdrawal. Treatments, both surgical and non-surgical, can be very effective.
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