Dee Anna Glaser, MD: How do you actually make the diagnosis? What steps do you feel you need to take to make that diagnosis of primary focal hyperhidrosis?

Adam Friedman, MD, FAAD: It’s all in the story. Fairly often in dermatology it’s a very visual field. If they walk in the door, we know whether someone has psoriasis or eczema, and of course there are many mimickers. But there, it’s in the tale that it’s been going on for a long time—greater than 6 months. It may have started early on, even though the patient probably didn’t realize it. That’s where engaging the patient is important. They may just be noticing it now because it’s interfering with shaking hands, or it’s requiring them to have multiple shirt changes throughout the day. But if you really delve into it, in terms of how they held their pencil or if they noticed that they were sweating more than their peers, they probably did notice but didn’t really understand that it was a medical issue. So, timing is key. Does it stop when they go to sleep? How often does it happen during the week? That is also very important. It should happen at least once a week, if not more. I’d be surprised if it was just happening once a week. I know it’s part of the criteria, but these patients are suffering with it every single day.

And as was also mentioned, family history is key. It’s not like this is something that they’re going to talk about at Thanksgiving dinner, but I do tell my patients to go back and ask their family members. And without fail, that person says, “Oh, yes, our family member always was a little extra sweaty. We just thought they were anxious.” This is very misleading because anxiety has nothing to do with it. We call primary hyperhidrosis idiopathic, which is a fancy way of saying that we have no idea why it happens. We also don’t have any idea why it would occur at any point in time. Temperature, anxiety, stress levels, what you’re eating, what you’re doing—it will come on regardless. That’s the unique element. It doesn't matter what you’re doing, it will come out.

Adelaide Hebert, MD: And that’s also one of the most troubling aspects. The patients can be, for example, sitting in a room that’s air-conditioned. Suddenly, they are sweating. They’re not anxious. They’re not worried. This is just spontaneous sweating that occurs for no known reason.

Dee Anna Glaser, MD: Adelaide, is there anything different that you do in the pediatric population to make the diagnosis, or is it still mostly about the history and excluding other causes by history?

Adelaide Hebert, MD: Well, I definitely want to ask about family history. I want to know the impact on the child’s life. I want to know where they are sweating. Most children start with palmar hyperhidrosis. That’s the most common area where we see the condition present in young children. I want to know how it impacts their school life, their social life, and their interactions. I want to know if they are on any medicines. For the most part, the parents will come in and say that they have noticed that their child is really sweating. Sometimes, the parental guilt comes out, because the parent has it, too. That provides me with the family history, and then I feel that I can successfully make the diagnosis.

Dee Anna Glaser, MD: I guess the question is, we know that this is common, right? It’s estimated as about 5% and, as you said, 15 million. How aware do you think dermatologists, other healthcare providers in the dermatology field, and even those outside of the dermatology realm are of hyperhidrosis?

Adam Friedman, MD, FAAD: I would like to think that our community is probably more aware than most. There is no question about it—this falls into our wheelhouse. Even for the in-office procedure, this is us. It’s dermatologists who are managing it. Outside of dermatology, it’s very unfortunate. I think it’s quite low, and this is not based on any statistic. It’s based on my own patients who come in telling me that they were told, “Don’t worry about it. Sweating is normal. It’s not a big deal. Use another antiperspirant,” which, of course, has multiple costs, both emotional and financial.

Overall, I think that the understanding of this as a medical problem, which we cannot emphasize enough, is very limited outside of dermatology. But even in dermatology, I have people coming from other dermatologists who refuse to do onabotulinumtoxinA injections or who just say they don’t know what to do about it. They won’t use oral anticholinergics. So, I think there’s definitely room for improvement in dermatology, but, especially outside of dermatology, there is a lot of room for improvement. There are huge gaps in education.

Dee Anna Glaser, MD: Yes, I agree with you. The pediatricians—how informed do you think they are?

Adelaide Hebert, MD: I think that’s where we have to really focus our education. I find that many of my colleagues in pediatrics have not been educated on this. I ask medical students who rotate from a variety of institutions, who work with us for a month or so on elective, if they’ve had a lecture on hyperhidrosis. The vast majority tell me they’ve never had a lecture on hyperhidrosis. When I have my hyperhidrosis clinic—and I know you run a hyperhidrosis clinic, too—many of the patients are so grateful to find a place that is interested in hearing about this and is actually caring for them. It’s like finding a medical home for this 1 component of their healthcare. It’s a great relief to them to find that we’re actually interested in taking care of them and their excessive sweating.

Dee Anna Glaser, MD: Yes. And I don’t think it’s any better in the realms of internal medicine or family medicine. I think there’s a huge area for improvement, as you said, in raising awareness. Andy, is this on the radar for insurance companies?

Andy Szczotka, PharmD: I wish I could be the contrarian to say that it’s definitely there. It’s really not. Very similar to what Adam had mentioned, I think there’s a huge gap in that process. It really isn’t necessarily on our radar screen, because we’re not seeing many patients who are seeking treatment, from a managed care perspective. And I think first-line therapies tend to be over the counter, so they’re not really hitting us. Patients are paying full out-of-pocket costs, and if they are seeking treatment, most of the therapy is very low usage and very low cost. So, it’s not really coming up at all. I think it’s really starting to hit our radar screen a little bit more with the advent of the indications for the botulinum toxins. Now we’re seeing that, and with their costs, we’re trying to get a little more interested. But as you’ve said, there’s a huge gap in knowledge and understanding that this is a medical condition.