We use cookies to ensure our website works properly and to personalise your experience. Cookies policy
Department of Pharmaceutics, Devaki Amma Memorial College of Pharmacy, Kerala 673634, India
Hyperhidrosis is a chronic condition of excessive sweating beyond the body’s requirement for thermoregulation. It is estimated to affect 2-5% of people and can cause serious damage to social functioning, mental health, physical health and work efficacy. Hyperhidrosis is of two types, primary and secondary. The most common sites of primary hyperhidrosis are the axillae, palms, soles and the craniofacial areas. Pathogenesis is due to deregulation of eccrine sweat gland activity and hyperactivity of the sympathetic nervous system. This review discusses the epidemiology, classification, anatomy and physiology of sweat glands, sweat regulation systems, diagnosis techniques and available treatments for hyperhidrosis. Management options include topical antiperspirants, iontophoresis, systemic anticholinergic medications, botulinum toxin injections, and surgical procedures including endoscopic thoracic sympathectomy and local sweat gland excision. Early diagnosis and personalized treatment plans are important to better symptom control and better quality of life of affected people. Numerous medicinal plants have been reported in the literature for their potential effectiveness in the management of hyperhidrosis. These plants may help reduce excessive sweating through mechanisms such as astringent activity, modulation of sweat gland function, anti-inflammatory effects, and control of sweat-associated microbial growth.
Hyperhidrosis is excessive sweating beyond that which is biologically required for thermoregulation and it often impacts upon social, emotional and occupational function. There are two types of this condition, primary and secondary. Primary hyperhidrosis is idiopathic, bilaterally symmetric, and involves profuse perspiration of the face, palms, soles, axillae, and (less often) the scalp or inguinal folds. Secondary hyperhidrosis may be localized or generalized and may be due to the use of medication or an underlying medical condition. [1,2] Two to five percent of people have hyperhidrosis, or excessive perspiration. Hyperhidrosis can be classified into two forms, namely secondary generalized hyperhidrosis (SGH) which is often associated with systemic disorders such as hyperthyroid disease or medications and primary focal hyperhidrosis (PFH) which usually involves localized areas such as palms, soles, axillae or face. SGH can occur at any age and requires treatment of the underlying cause whereas PFH is usually seen around adolescence or early adulthood [3]. Excessive perspiration can have a significant effect on patients’ physical, psychological and social well-being, resulting in stigma, humiliation and reduced quality of life.[4] The pathophysiological mechanisms of hyperhidrosis including sympathetic nervous system hyperactivity and deregulation of sweat gland function. [4] need to be understood in order to tailor effective treatments. Hyperhidrosis has a significant impact on the psychological, social and even economic aspects of life and hampers the daily activities. [3] The disease brings a lot of burden for the patients that makes them withdraw and feel more self-conscious.[5] They may also be worsened by stress and emotions, creating a vicious cycle. [5] Recent research shows that hyperhidrosis is correlated with an increased risk of mental disorders such as depression. [5] Hyperhidrosis also directly affects skin health because it disrupts the natural defenses of the skin. As a result, dermatoses, especially of fungal, bacterial and less often of viral origin, are more frequent in affected patients.[4] Therefore, excessive perspiration is a complex problem that needs careful expert care supported by state-of-the-art hyperhidrosis treatment methods. [3]
2.EPIDEMIOLOGY
Hyperhidrosis is more common in women and often underdiagnosed due to the stigma and lack of knowledge around it. Genetic predisposition is seen in approximately 30 to 50 percent of PFH cases, and the disorder tends to be familial.[6] On the other hand, SGH is generally a side effect of diseases such as diabetes, obesity or neurological problems.[7] The worldwide prevalence varies from 0.072% to 9%, according to the various demographics and research types. Higher percentages have been found in different European countries, but the frequency in the United States has been estimated to be between 2.8 and 4.8% of the population. Primary hyperhidrosis accounts for approximately 93% of hyperhidrosis cases.[8] Palmar hyperhidrosis is often preceded by axillary hyperhidrosis, and primary hyperhidrosis usually begins in infancy or adolescence. The disease is almost equally common in males and females, although there may be differences in health seeking behavior in the two sexes. About 30-50% of patients have a family history suggesting a strong genetic propensity. [9] The most common areas of involvement are the axillae, palms, soles, and craniofacial region. Hyperhidrosis can have a severe influence on quality of life through social embarrassment, emotional anguish, difficulty at work and lower productivity. However, because of its extensive distribution and impact, many affected people do not seek medical attention and lead to underdiagnosis and undertreatment. [10] Primary hyperhidrosis is the most common condition among people aged 20 to 25 years. Symptoms usually begin between the ages of 14 and 25 and slowly become less severe. If any person over 60 years old develops any symptoms of hyperhidrosis, doctors should investigate secondary sources of this ailment. [3]
3.CLASSIFICATION OF HYPERHIDROSIS
3.1Primary hyperhidrosis
The aetiology of primary hyperhidrosis is idiopathic and the highest prevalence was observed in young people without comorbidities. Moreover, a positive family history of the condition can be detected in around 30–50% of cases, which indicates a possible genetic background of the hyperhidrosis. Hyperhidrosis is frequently limited to a single site or several sites in a symmetric distribution. The most frequent sites are axillae (about 50%), soles (about 30%), palms (about 25%) and face (about 20%). [9,3] Patients may report symptoms such as sweaty marks on clothes, shoes or objects they touch (such as paper sheets), noticeable drops of sweat on the forehead, moist handshakes, or feeling of body smell. The most common type of excessive sweating is episodic and can be caused by emotions and stress. throughout addition, symptoms occur throughout daylight and disappear over sleep. [11,12]
3.2 Secondary hyperhidrosis
By contrast, secondary hyperhidrosis is generally seen in older people and may be caused by fever, physiological processes such as menopause or pregnancy, concomitant systemic disorders, bad drug reactions or consequences from medical operations (such as thoracic sympathectomy). In contrast to the primary form of the disease, secondary hyperhidrosis typically presents as generalized excessive sweating. And the symptoms can also be presented as foci locally localized asymmetrically. In addition, the disease is commonly presented in the form of night sweats during sleep and it is not associated with any genetic heritage. [13] Several systemic conditions potentially impair the body's thermoregulatory homeostasis. Hyperhidrosis should be properly diagnosed and any secondary causes excluded. The most frequent precipitating factors are proliferative diseases, endocrinopathies, cardiac, viral, nervous system, metabolic and psychiatric disorders. [9, 12] Excessive perspiration can also be caused by adverse reactions to a wide range of common medications, including opioid analgesics and cyclooxygenase inhibitors, antibiotics and antivirals, cardiac and hypotensive drugs, antidepressants and mood stabilizers, anticholinergic agents, antipyretics, hypoglycemic agents, and topical preparations .[14]
Table: The most common triggering factors of the secondary hyperhidrosis [10,12,14]
|
Category |
Examples |
|
Physiological Conditions |
Menopause, pregnancy, fever |
|
Haematological and Neoplastic Disorders |
Myelodysplastic syndromes, Hodgkin lymphoma, other proliferative diseases |
|
Endocrine Disorders |
Hyperthyroidism, pheochromocytoma, diabetes mellitus with hypoglycaemia, carcinoid syndrome, hypopituitarism, pituitary tumours, acromegaly |
|
Cardiovascular Diseases |
Heart failure, infective endocarditis |
|
Infectious Diseases |
Influenza, HIV infection, tuberculosis, encephalitis |
|
Neurological Disorders |
Pituitary stroke, spinal cord injuries, Parkinson’s disease, familial dysautonomia, polyneuropathies |
|
Metabolic Disorders |
Obesity |
|
Psychiatric Conditions |
Alcohol use disorder, generalized panic disorder, social anxiety disorder |
|
Medication-Induced Hyperhidrosis |
Opioid analgesics (e.g., morphine, oxycodone, fentanyl, tramadol), nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, antiviral agents, antihypertensive medications, antidepressants, antipsychotics, mood stabilizers, and antidiabetic agents such as insulin and sulfonylureas |
|
Topical Agents |
Glucocorticosteroid-containing preparations |
4.Anatomy and physiology of sweat glands
The skin is the largest organ of the human body and is critical to the maintenance of homeostasis, especially by thermoregulation. This is mainly due to the sweat glands, specialised skin appendages that are located in the dermis, and secrete perspiration that evaporates from the skin surface and takes heat from the body .[3,17]
Sweat Glands
Sweat glands are divided into two categories: eccrine and apocrine sweat glands, which produce various forms of sweat. Eccrine sweat glands are important in thermoregulation. There is a third type of sweat gland, the apoeccrine sweat gland. [15,16,17]
Eccrine Glands
Eccrine glands are functional at birth. They are found over the entire body surface except on the lips and glans penis. They are the only sweat glands on the palms of the hands and soles of the feet. The eccrine glands are composed of a spiral of one layer of secretory cells (clear, dark and myoepithelial cells) (anatomically). Excretory duct opens directly on surface of skin. Eccrine glands secrete a watery fluid that plays a role in thermoregulation. [18,19,17] Sympathetic nerve fibers stimulating eccrine glands use acetylcholine (ACh) [18] as the main neurotransmitter. They react to temperature and emotional stimuli. [19]
Apocrine Glands
Apocrine glands are present at birth, but they are not functional until puberty. They are found in the axillae, breast, scalp and perineum but not in the palms of the hand and soles of the feet. The secretory part of the gland consists of a single layer of epithelial cells surrounded by myoepithelial cells. The apocrine glands are larger than the eccrine glands and their excretory duct open into hair follicle. The sweat of these glands is a viscid fluid which gives off a body smell, which is felt as a body smell. But what the apocrine glands are for is unknown .[19,20]
Apoeccrine
Apoeccrine glands are thought to be the more developed form of eccrine glands after puberty. They are said to occur in the hairy parts of the body, such as the axilla, mammary, perineal and vaginal region. Their excretion channel opens directly on to the skin surface and secretes a watery secretion similar to eccrine sweat. The secretory coil is similar to the apocrine glands. The precise physiological role of apoeccrine glands remains unclear but they are unlikely to be essential for thermoregulation .[17,19,20]
5.MECHANISMS OF SWEAT REGULATION AND SECRETION
The secretion of sweat is regulated by signal transduction from the central nervous system (CNS) to the peripheral autonomic nervous system (ANS). [15] The ANS receives signals from the CNS and secretes neurotransmitters and peptides that regulate activation of sweat glands. Acetylcholine (ACh) is the principal neurotransmitter of thermal sweating and regulates the eccrine glands. Catecholamines (e.g. noradrenaline) regulate eccrine and apocrine glands in sweating in response to emotional stress. [15, 21]
6.Evaluation of hyperhidrosis
Establishing the diagnosis of hyperhidrosis
The evaluation of patients with HH is almost entirely based on a detailed history of the patient and supportive physical examination. Further testing is seldom associated with further laboratory work or specific investigations of sweating. Perhaps the most important and sometimes overlooked aspect of the assessment is the basic knowledge that HH is a common, disabling and potentially treatable condition. Goals of evaluation and management of the patient with excessive sweating are:
• To establish a diagnosis and to rule out secondary causes
• To assess the severity of the HH
• To establish a correct treatment strategy. [22]
6.1 Physical examination
Physical examination may be normal, but will often reveal obvious areas of focal sweating or skin maceration. The primary objective of physical examination is to reveal any evidence of underlying chronic illness suggestive of a secondary cause, for example lymphadenopathy. [23]
6.2 Laboratory tests
Laboratory tests are not required to make a diagnosis of primary HH. They only serve to rule out and work-up potential secondary causes of sweating. Work-up for generalized sweating or secondary HH can be complicated, and often includes a number of investigations, the details of which are beyond the scope of this chapter. [2]
6.3 Specialized tests
Once primary HH has been diagnosed the next step in the examination is to assess the severity of the problem since this will help guide management. The best measure of severity of sickness is the experience of the particular sufferer. However, the rate and amount of sweat generation can be quantified or qualified using gravimetric testing, evaporimetry, the Minor starch-iodine test and the ninhydrin test. Similarly, a number of quality-of-life measures connected to HH have been created and validated including the Hyperhidrosis Disease Severity Scale (HDSS), the Hyperhidrosis Impact Questionnaire (HHIQ), the Dermatology Life Quality Index (DLQI) and the Illness Intrusive Rating Scale (IIRS). The HDSS is the simplest and easiest to administer of these, and comprises of four questions, each of which adds a point to a total score of 4. The HDSS score is simple to reproduce and directly guides management decisions. These specialized tests have been reviewed informatively and up-to-date by Solish and colleagues. [23]
|
HDSS Score |
Patient Assessment |
Severity |
|
1 |
Sweating is never noticeable and never interferes with daily activities. |
Mild |
|
2 |
Sweating is tolerable but sometimes interferes with daily activities. |
Moderate |
|
3 |
Sweating is barely tolerable and frequently interferes with daily activities. |
Severe |
|
4 |
Sweating is intolerable and always interferes with daily activities. |
Severe |
7. Treatment for hyperhidrosis
7.1 Nonsurgical management
The right treatment will be different for each patient, depending on the location of focal HH, severity and patient tolerance. Hence, a pre-defined algorithm would not be applicable to all subsets of focal HH. But most patients should start with nonsurgical therapies. Conservative treatment can be divided broadly into: topical antiperspirants, iontophoresis, systemic medications, botulinum toxin (BTX) injection or a combination of these. [24]
7.11Antiperspirants
Topical antiperspirants are commonly the first-line treatment for palmar, plantar and axillary HH because of their ease of application, excellent efficacy and safety, and low cost.[25,26.
Short-acting topical antiperspirants provide only temporary relief from sweating. They are most useful in mild to moderate HH cases (HDSS score 1 or 2). There are many different topical antiperspirants. The most common and most effective of the over-the-counter and prescription antiperspirants contain aluminium salts, most commonly aluminium chloride. Other topical therapies that combine anti-cholinergic drugs, aldehydes and anesthetic agents are available but are often less effective and limited by severe skin irritation at the concentrations required. [26,27] The mechanism of action is thought to be a physical blockage of the sweat gland pore and/or atrophy of the secretory cells [28]. Most popular OTC antiperspirant products contain up to 12.5% aluminium chloride and most prescription preparations contain 20 to 25%, however they may contain as much as 35%. The most limiting adverse effect of aluminium chloride is skin irritation, leading to discontinuation in up to 21% of patients. [27]
7.12 Iontophoresis
A non-invasive technique applying electrical currents to reduce sweating, mainly for palmar and plantar hyperhidrosis. [29] The mode of action is unclear although it is thought that the electrical charge disrupts normal eccrine sweat secretion [30]. Iontophoresis is a second-line therapy for mild palmar and plantar HH (HDSS score 2) and a first-line therapy for severe (HDSS score 3 or 4) palmar or plantar HH when used in combination with aluminium chloride [23]. The treatment involves immersing the hands or feet in a water bath through which an electrical current of 15–20 mA is passed for 20–30 min, three to four times per week .[23] Requires long-term maintenance therapy. The use of this modality has not been studied in large randomized trials, but in smaller series it has been useful in more than 80% of people with palmar or plantar HH.[22,23] Side effects are rare, and are limited to skin irritation. Contraindications: Pacemakers, defibrillators or metallic surgical implants, pregnant patients.
7.13 Systemic medications
Many oral drugs have been documented for the management of HH. The most prevalent agents are anticholinergic pharmaceuticals such as glycopyrrolate or oxybutynin. Anticholinergics compete for the muscarinic receptor and thereby interfere with synaptic acetylcholine signalling. Most patients usually react to anticholinergics but their utility is restricted by the severe side effects that tend to arise at the levels required to minimize perspiration. [27,31] Glycopyrrolate is usually the systemic medicine of choice, dosed at 1–2 mg up to three-times a day. The adverse effects of anticholinergics are specifically:
7.14 Botulinum toxin therapy
Treatment with botulinum toxin type A (BTX-A) is another option for the treatment of hyperhidrosis. It is a neurotoxin produced by the anaerobic bacterium Clostridium botulinum.(29) This treatment method works by preventing the release of acetylcholine in the neuromuscular junction and crucially, in the postganglionic sympathetic fibers innervating the sweat glands which leads to the secretion of local anhydrase. (29, 32) Botulinum toxin type A appears to be an effective, safe and well tolerated option for the treatment of primary hyperhidrosis. The complications in patients treated with this method are the appearance of antibodies to the toxin, which involves a significant decrease of the efficacy of the treatment in subsequent therapeutic sessions, and the pain, especially in the case of TB-A palmar administration, which often requires local blockade of the ulnar and intermediate nerve. Furthermore, TB-A can invade the adjacent motor palmar muscles leading to impairment of the ability to perform fine finger movements. (29) Dyspepsia and pyrosis are other problems.
7.2 Surgical interventions
7.21 Endoscopic thoracic sympathectomy (ETS)
Endoscopic thoracic sympathectomy (ETS) is the gold standard surgical treatment for palmar, face and axillary hyperhidrosis with a success rate of >95% [33]. For serious patients who do not respond to other treatments. This includes the cutting or clamping of sympathetic nerves but may result in compensatory hyperhidrosis. Compensatory sweating (CS), the most feared and common side effect of thoracic sympathectomy, is a phenomenon characterized by increased sweating in areas distal to the level of sympathectomy. [6]
7.22 Local sweat gland removal:
Refractory axillary hyperhidrosis can be treated with laser or surgical excision. Local sweat gland excision is a minimally invasive surgical procedure for axillary (underarm) hyperhidrosis that has not been cured with conservative therapies such as topical antiperspirants, iontophoresis, oral medications or botulinum toxin injections. The technique is aimed at permanent reduction of perspiration by destruction or removal of the eccrine sweat glands in the dermis and subcutis of the axilla. Under local anesthesia, small cuts are made in the armpit skin during the procedure. Scraping, suctioning or mechanical disruption of the sweat glands is achieved by inserting a curette or liposuction cannula beneath the skin. Methods include superficial liposuction, curettage, and liposuction-curettage, the latter usually being more effective in reducing perspiration as it removes glands from both the deep dermis and the subcutaneous tissue. [34,35]
Microwave thermolysis
Refractory axillary hyperhidrosis can be treated with laser or surgical excision. Local sweat gland excision is a minimally invasive surgical procedure for axillary (underarm) hyperhidrosis that has not been cured with conservative therapies such as topical antiperspirants, iontophoresis, oral medications or botulinum toxin injections. The technique is aimed at permanent reduction of perspiration by destruction or removal of the eccrine sweat glands in the dermis and subcutis of the axilla. Under local anesthesia, small cuts are made in the armpit skin during the procedure. Scraping, suctioning or mechanical disruption of the sweat glands is achieved by inserting a curette or liposuction cannula beneath the skin. Methods include superficial liposuction, curettage, and liposuction-curettage, the latter usually being more effective in reducing perspiration as it removes glands from both the deep dermis and the subcutaneous tissue. [34,35]
Suction curettage
Axillary hyperhidrosis: tumescent liposuction curettage or minimal excision with curettage for removal of eccrine glands. The latter is only marginally more successful but has a higher risk of scarring and serious morbidity, so suction curettage is preferred. A cannula is then inserted after administration of tumescent anesthetic to remove superficial subcutaneous tissue with eccrine glands. The best method is sharp suction curettage. [34] There are few studies of its long-term effectiveness, but, because the glands are completely removed, perspiration may be permanently decreased. The patients are very satisfied after the successful destruction of the eccrine glands and the subsequent reduction of sweating.
Emerging therapy
Limited data exist for the use of non-invasive lasers, subdermal lasers, ultrasound, and radiofrequency devices for hyperhidrosis. Currently these therapies are not recommended for general treatment of focal hyperhidrosis. [6]
Laser treatments
Targets sweat glands without affecting surrounding tissues.
Topical novel agents
Research on new anticholinergic formulations with fewer side-effects is ongoing..
7.3 Herbals used for treatment
Treatment options include topical antiperspirants, iontophoresis, botulinum toxin injections, systemic anticholinergic agents and surgery. But some patients seek complementary and alternative therapies because they are worried about side effects, availability of treatment or cost. Herbal remedies for excessive sweating have been used traditionally in many different medical systems including Chinese medicine, Ayurveda and Western herbal medicine. Medicinal herbs sometimes contain astringent, anticholinergic, anti-inflammatory or anxiolytic compounds that can reduce sweat production or treat the causes of sweating. In the past, people have used herbs for perspiration, such as witch hazel (Hamamelis virginiana), green tea (Camellia sinensis), chamomile (Matricaria chamomilla) and sage (Salvia officinalis).[36]
1. Witch Hazel for Hyperhidrosis Witch hazel may be new to you, but if you are looking for herbs that can help with hyperhidrosis, then it’s time to get to know it. Witch hazel is a natural herb that has anti-perspirant and astringent properties. So it basically kills perspiration by drying out your skin and locking up the pores. This hyperhidrosis herb can be applied directly to the areas you sweat, or ground with water to make a paste that you can leave for about an hour before rinsing off with water.
2. Sage for Too Much Sweating
Another great plant for hyperhidrosis is sage. Sage leaves have tannic acid, which tightens the sweat ducts and reduces sweating. Sage comes in the form of tablets, pills or tea. Any herbal tea in general can help your body to battle the symptoms of hyperhidrosis a lot.[37]
3. White Sandalwood Powder
Another natural remedy for hyperhidrosis is white sandalwood powder which is not a herb at all. Take a spoonful of this powder and mix it with lemon juice and rose water; this is an effective therapy for hyperhidrosis at home. Apply to the skin and allow it to dry for about 25 minutes then wash off.
4. Aloe barbadensis Miller or Aloe vera
Aloe vera is applied topically in cases of irritations associated with hyperhidrosis and may have a slight cooling effect.
5. Camellia sinensis (Green tea) .
Green tea contains polyphenols and tannins which have a mild astringent effect and reduce sweating, whether taken internally or applied topically. [36]
6. Glycyrrhiza (Glycyrrhiza glabra)
Licorice (Glycyrrhiza glabra) is a medicinal herb, which is widely used in traditional medicine as an anti-inflammatory, antioxidant, and antibacterial agent. The primary active ingredient is glycyrrhizin which soothes inflamed skin and decreases the inflammation caused by excessive sweating. Although no definitive evidence exists on the antihyperhidrotic activity of licorice, it may improve skin comfort and reduce some symptoms such as irritation and microbial overgrowth in patients with hyperhidrosis. [38]
7. Vetiver Grass (Chrysopogon zizanioides)
Vetiver (Chrysopogon zizanioides) is a scented grass and has been a traditional herb in Ayurvedic medicine. Vetiver roots have soothing, cooling and anxiolytic effects that could help to reduce stress-induced sweat Traditionally the Vetiver essential oil is used to provide relaxation and a cooling sensation. These properties may make vetiver a useful treatment for the symptoms of hyperhidrosis, especially when emotional stress is a cause. [39]
8. Arrowroot, or Maranta arundinacea
Arrowroot (Maranta arundinacea) is a natural starch that is used in medical and cosmetic compositions for its excellent moisture-absorbing properties. Arrowroot powder is a great adjunct to a topical treatment as it wicks excess moisture away from the surface of the skin keeping the area dry and comfortable. Arrowroot is non-irritating and highly absorbent, which makes it a popular ingredient in herbal dusting powders and natural anti-perspirant formulas to help control excessive sweat. [40]
CONCLISION
Hyperhidrosis is a common but often undiagnosed illness that can greatly affect a person’s quality of life. Understanding its classification, underlying pathophysiology and clinical presentation is required for correct diagnosis and successful treatment. Treatment possibilities are diverse and vary from intensive treatments with botulinum toxin injections and surgery to more conservative approaches such as topical antiperspirants and iontophoresis. When deciding what treatment to give, one needs to examine the degree of the sickness, which area of the body is sick, what the patient wants, and how the patient reacted to past treatments. Recent advances in minimally invasive and novel therapy procedures have provided more options to patients with refractory symptoms. Early diagnosis and adequate response allowed to enhance clinical outcomes and overall well-being. Natural remedies such as sage, green tea, witch hazel, chamomile, aloe vera, apple cider vinegar, and tea tree oil may provide symptomatic relief in hyperhidrosis through astringent, anti-inflammatory, antimicrobial, or sweat-reducing effects
REFERENCES
Priyanka P, Nethaji Ramalingam, Abhirami P. P, Anagha U. V, Haritha K. K, Hyperhidrosis: A Comprehensive Review of Pathophysiology, Diagnosis, Conventional Therapies, and Herbal Management Approaches, Int. J. of Pharm. Sci., 2026, Vol 4, Issue 6, 5583-5593, https://doi.org/10.5281/zenodo.20796538
10.5281/zenodo.20796538