Derm Dx: A child with excessive sweating - Clinical Advisor

Derm Dx: A child with excessive sweating

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  • Hyperhidrosis 1_1112 Derm Dx

  • Hyperhidrosis 2_1112 Derm Dx

  • Hyperhidrosis 3_1112 Derm Dx

A 9-year-old female presents complaining that she has experienced excessive sweating of her palms and soles for several years. The patient finds it extremely socially embarrassing and is afraid to shake anyone’s hand.

The patient also reports dripping sweat onto her papers at school and occasionally has trouble gripping her pen or pencil because of the excessive moisture. She says she cannot wear flip-flops or sandals because her feet slip.

The patient is otherwise healthy. A complete review of symptoms is negative. Her family history is significant for identical symptoms in her father.

Primary hyperhidrosis is defined as focal and visible excess sweating present for at least six months and for which there is no underlying cause. The sweating should be bilateral and symmetric and stop during sleep.  Primary hyperhidrosis most commonly occurs...

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Primary hyperhidrosis is defined as focal and visible excess sweating present for at least six months and for which there is no underlying cause. The sweating should be bilateral and symmetric and stop during sleep. 

Primary hyperhidrosis most commonly occurs in a palmoplantar distribution. Axillary hyperhidrosis may occur either in association with or independently from palmoplantar hyperhidrosis. Palmoplantar hyperhidrosis usually develops during childhood, whereas axillary hyperhidrosis onset is puberty. The majority of cases are associated with a positive family history.

In palmoplantar hyperhidrosis the entire palm and sole — as well as the fingertips —  display excessive sweating. This can lead to both social and occupational impairment. Patients are embarrassed to shake hands, and work or school materials are frequently contaminated with the excessive sweat.  

In axillary hyperhidrosis patients experience staining of their clothing, as well as sweat dripping down their trunk. Hyperhidrosis is due to over activity of the eccrine sweat glands, which are not odorogenic like apocrine sweat glands. Therefore, excessive body odor is not a frequent complaint in hyperhidrosis. 

Secondary hyperhidrosis is defined as excessive sweating associated with or due to an underlying genetic or systemic disorder. The list of these disorders is exhaustive. Examples of systemic disorders that may cause hyperhidrosis include hyperthyroidism, carcinoid syndrome, and menopause. 

An example of a genetic disorder is familial dysautonomia in which hyperhidrosis occurs on the face and trunk and may be associated with other signs and symptoms such as postural hypotension, impaired lacrimation, developmental delay, decreased deep tendon reflexes and “dysautonomic crises,” in which the patient develops vomiting and hypertension. 

Another form of hyperhidrosis is gustatory hyperhidrosis. Gustatory hyperhidrosis may be physiologic or pathologic. Physiologic gustatory hyperhidrosis occurs in normal individuals with no underlying disorder when the taste buds are stimulated by certain foods or drinks. The affected patient experiences excessive sweating of the cheeks and upper cutaneous lip. The most common triggers are spicy foods, fruit and alcohol. 

In pathologic gustatory hyperhidrosis the symptoms develop due to disruption of nerves. The nerve disruption may be due to surgery, herpes zoster, tumors, abscesses or any other process that disrupts the nerves.

Frey’s syndrome describes gustatory hyperhidrosis following surgery to the parotid gland and occurs in the distribution of the ipsilateral auriculotemporal nerve. Frey’s syndrome may occur in up to one-third of patients following parotid surgery. 

Certain medication classes such as cholinesterase inhibitors and antidepressants may also lead to generalized excessive sweating.

Diagnosis

In primary hyperhidrosis patients experience excessive sweating in a palmoplantar and or axillary distribution, with the onset during childhood or around puberty. Physical exam demonstrates shiny, wet palms and soles or significant axillary perspiration. 

In classic cases of primary hyperhidrosis, further workup is not generally indicated. However, if the history or physical exam points to secondary hyperhidrosis then appropriate referral and workup should be arranged. 

Treatment

Primary hyperhidrosis treatment includes topical aluminum chloride antiperspirants, iontophoresis, injections of botulinum toxin A, oral anticholinergics, surgical excision or sympathectomy. 

References

  1. Bolognia J, Jorizzo JL, Rapini RP. ” Chapter 40: Diseases of the Eccrine and Apocrine Sweat Glands.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2008.
  2. James WD, Berger TG, Elston DM et al. “Chapter 33: Diseases of the Skin Appendages.” Andrews’ Diseases of the Skin: Clinical Dermatology. Philadelphia: Saunder Elsevier, 2006.
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