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Supplements Examining Hyperhidrosis (Excessive Sweating): A Managed Markets Update on New Treatments, Featuring a Patient Perspective
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Hyperhidrosis and Its Impact on Those Living With It
Mary Lenefsky, PharmD, and Zakiya P. Rice, MD
Participating Faculty
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Hyperhidrosis and Its Impact on Those Living With It

Mary Lenefsky, PharmD, and Zakiya P. Rice, MD
Sweating plays a vital role for humans. However, excessive sweating, also called hyperhidrosis, is a condition resulting in sweating beyond what is physiologically necessary. The increased rate of sweating is not caused by external stimuli or temperature fluctuations, as with an individual without hyperhidrosis. Hyperhidrosis affects approximately 4.8% of Americans. Primary hyperhidrosis, a specific classification of the disease, primarily affects younger adults aged 18 to 39 years, and it often has a genetic component. Living with hyperhidrosis presents many challenges and impacts numerous aspects of daily life. Patients with hyperhidrosis are impacted in their social and professional lifestyles, as well as their mental and emotional health. These negative effects, which have been studied, lead to a lower quality of life (QOL) in this population. Additionally, constant moisture from sweating can lead to skin maceration. This increases the risk of skin conditions such as athlete’s foot and more severe conditions such as bacterial infections or pitted keratolysis. Study results report a nearly 30% greater risk of skin infections in patients with hyperhidrosis compared with healthy controls. This section of the continuing education supplement will examine the pathophysiology and clinical severity of hyperhidrosis and identify the comorbidities and QOL challenges associated with this condition.
Am J Manag Care. 2018;24:-S0
Sweating plays an essential role in the daily lives of humans by maintaining body temperature, responding to emotional stress, and assisting in metabolism. The human body contains 2 types of sweat glands, eccrine and apocrine glands, which begin to form as early as the third month of fetal development.1

Eccrine glands are located throughout the body. They are involved in thermoregulation and constitute 90% of the total number of sweat glands. Eccrine glands are more effective than apocrine glands in releasing fluids and electrolytes to maintain body temperature. They can also release up to 3 liters of odorless fluid per hour. In contrast, apocrine glands are found in specific areas of the body, particularly the axillae, pubic area, and ear canal. Apocrine glands secrete sweat along with proteins and other chemicals including pheromones and steroids. The distinct odor released by apocrine glands result from bacteria-producing urea.1

In humans, sweat secretion is regulated by the central nervous system (CNS) and the autonomic nervous system (ANS). There are 2 main neurotransmitters involved in sweat regulation. Acetylcholine (ACh) regulates thermal sweating via eccrine glands, and catecholamines, such as noradrenaline, regulate both types of glands in emotional or stress-induced sweating.1 When sweat regulation functions properly, the ANS can control sweating to adjust to changes in the environment, metabolism, temperature, or emotion.1

Hyperhidrosis is the term used to describe a condition of excessive sweating beyond what is physiologically necessary.2 It can be either systemic or localized, based on the distribution of sweat, and is also classified as primary or secondary, based on the cause of sweating.3 Systemic hyperhidrosis describes sweating over the entire body; localized sweating affects only certain parts of the body.4 Primary focal hyperhidrosis presents as local sweating, such as in the axillae (underarms), palms (hands), soles (feet), and craniofacial regions. Other areas include, but are not limited to, inframammary, groin, and gluteal folds. These sites on the body are primarily affected because of the presence of large numbers of sweat glands.3,5 The axillae are most commonly affected, followed by the palms and soles.6

There is no difference in morphology, number, or size between the sweat glands of a patient with hyperhidrosis and an individual without hyperhidrosis.3,7 In patients with hyperhidrosis, the sweat glands are overstimulated by ACh that is released by the sympathetic nervous system.7,8 These patients appear to have a reduced threshold for emotional sweating, despite having normal responses to thermoregulatory sweating.

Primary and Secondary Hyperhidrosis

Hyperhidrosis can be divided into primary and secondary hyper-hidrosis. This report focuses on primary hyperhidrosis. However, it is important for healthcare practitioners to differentiate between primary and secondary classifications. In some cases, the cause of increased sweating can be alleviated.

Primary hyperhidrosis is not caused by external stimuli, body temperature, or association with a systemic disease.7,9 The central mechanism of primary hyperhidrosis is largely unknown.3 It is speculated that primary hyperhidrosis is a combination of a lowered threshold and exaggerated response to sweating.10 The sweating pattern in primary hyperhidrosis is often focal. While generalized sweating can occur, it appears to be less common.11

In contrast, secondary hyperhidrosis (which can also be focal or generalized) is due to other modalities, such as medications, malignancies, endocrine disturbances, or other CNS issues.3,8 Table 1 highlights some of the most common causes of secondary hyperhidrosis.3,4 It is important for a healthcare practitioner to be able to distinguish between primary and secondary hyperhidrosis, as the 2 forms may require different management and treatment.3

Practitioners should be aware of other major differences between primary and secondary hyperhidrosis. In primary hyperhidrosis, sweating is in a typical distribution.11 Additionally, there is a positive family history in approximately 35% to 55% of cases. At the onset of disease, patients are most often aged between 14 and 25 years.

In secondary hyperhidrosis, the onset is usually later than 25 years of age. The sweating pattern is often unilateral, asymmetric, and more generalized rather than focal. Secondary focal hyperhidrosis is rather rare. Additionally, patients often experience symptoms during sleep. A positive family history is also less common in secondary hyperhidrosis.3,11

Who Is Affected by Hyperhidrosis?

Primary hyperhidrosis reportedly affects 4.8% of Americans, or approximately 15.3 million individuals.2,12 Because it is often underreported and underdiagnosed, the true prevalence rates may be higher.13 As previously mentioned, the age of onset of primary hyperhidrosis is often between 14 and 25 years. However, it is also seen in infants because eccrine sweat glands are fully functional at birth.11 It primarily affects younger adults aged 18 to 39 years. Rates are lowest among those 65 years and older, young children, and adolescents.2,3 It is speculated that lower prevalence among the elderly population is due to disease regression over time.11 Incidence rates do not appear to differ between genders.11 However, men may be more likely to be affected in craniofacial areas, although women are more likely to be affected in axillae areas.11 Some literature suggests a possible racial difference in the prevalence of primary hyperhidrosis, with more Japanese American patients affected by hyperhidrosis in the palms and soles.3

Living With Hyperhidrosis

In many cases, healthcare professionals may underestimate what patients with hyperhidrosis experience daily. They must overcome obstacles that many people without hyperhidrosis would never consider, such as multiple daily showers, extra changes of clothing, difficulty opening doors, and feelings of depression and anxiety.5

It is well documented that hyperhidrosis negatively affects numerous aspects of life. Worldwide, nearly one-third of patients with hyperhidrosis report they are “frequently or constantly bothered” by the sweating they experience. Some studies report that 40% of patients with hyperhidrosis experience physical discomfort.5,14 Sweating can range from mild dampness to overt dripping.13 Regardless, the constant sweating can lead to an impairment of daily activities and work life.5 Results of a study from India demonstrated that 38% of college-aged students with hyperhidrosis (aged 17-21 years; N = 375) experienced bothersome to extremely bothersome symptoms.15 In another study from the United States, approximately 75% of respondents with hyperhidrosis indicated that their sweating led to negative effects on their social life and emotional and mental health.13 Other patients have reported a reduced effectiveness at work, with up to 80% of respondents being affected, and up to 86% of patients reporting a moderate to severe emotional impact from the disease.5,6

Table 2 summarizes the impact of hyperhidrosis.5,14 The table is divided into 4 large categories: general lifestyle, social life, mental impact, and professional life. For each of these categories, specific examples are provided. Some or all of these aspects may be affected, depending on which areas of the body are affected by excessive sweating.

In a review of Table 2, it is evident that hyperhidrosis has widespread implications, ranging from what a patient has for lunch to the career path they choose to follow.5,14 Given the daily challenges that arise with the disease, patients with hyperhidrosis employ many strategies to cope. Strategies include carrying around a change of clothes and extra sets of towels, keeping a fan nearby, making meals at home, and/or bathing several times daily. As reported in a study by Kamudoni et al, 50% to 70% of individuals with hyperhidrosis changed their clothes more than twice a day and spent an extra 15 to 60 minutes daily on managing their symptoms.5

When working with patients with hyperhidrosis, healthcare practitioners need to understand the many aspects of life this disease affects. By keeping factors from Table 2 in mind, a healthcare practitioner will be better prepared to care effectively for this patient population.5,14

Impact of Hyperhidrosis on Quality of Life

Quality-of-life (QOL) studies are used to measure the effect a disease has on an individual. However, in the case of hyperhidrosis, QOL studies are also used to prove efficacy of certain therapeutic interventions.

Hyperhidrosis negatively affects QOL and, as such, numerous QOL assessment tools are used to evaluate the condition. The Hyperhidrosis Disease Severity Scale (HDSS) grades the tolerability of sweating and its impact on daily life on a 4-point scale. Grade 1 indicates sweating is never noticeable and never interferes with daily activities. Grade 4 indicates sweating is intolerable and always interferes with daily activities. The QOL Index is similar to the HDSS and rates the impact of the disease on a 3-point scale. The Hyperhidrosis Impact Questionnaire asks questions related to characteristics of the disease, medical resource usage, and limitations that the patient experiences. Given that the disease directly affects the skin, the Dermatology Life Quality Index is also used. More general tools, such as the 36-item Short Form (SF-36) Health Survey, may be used in studies assessing QOL.7,14

QOL appears to be directly impacted by the specific body parts affected by hyperhidrosis.6 Shayesteh and colleagues noted that HDSS and SF-36 results showed that axillary hyperhidrosis, compared with other regions, most severely impacted patients’ QOL.6 However, this is debated, as other studies have shown no difference in QOL based on manifestation of the disease.1

 
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