Hyperhidrosis

Hyperhidrosis means excessive sweating beyond what is required for normal cooling of the body.

Primary focal hyperhidrosis usually affects specific body regions.

Common sites include:

• Palms.
• Soles.
• Axillae.

More than one area may be affected in the same child.

Sweating is often relatively symmetrical and may become worse with stress or warm conditions, although it can also occur without an obvious trigger.

In primary focal hyperhidrosis, excessive sweating generally decreases significantly during sleep.

Sweating affecting most of the body, starting suddenly or occurring prominently during sleep may lead the clinician to investigate a secondary cause.

Hyperhidrosis does not cause the same degree of difficulty for every child.

Mild disease may be a manageable inconvenience.

Severe palmar sweating, however, can cause:

• Wet school papers.
• Difficulty holding a pen or pencil.
• Difficulty using touchscreens.
• Objects or sports equipment slipping from the hands.
• Difficulty with fine motor tasks.
• Avoidance of handshakes or holding hands.
• Embarrassment and social anxiety.

Severe plantar sweating may create persistent moisture inside shoes and contribute to skin irritation.

Axillary sweating may repeatedly soak through clothing.

The effect on everyday life is an important part of assessing disease severity and deciding how aggressively it should be treated.

Before diagnosing primary hyperhidrosis, the possibility of another cause should be considered.

Primary focal hyperhidrosis commonly:

• Begins relatively early in life.
• Affects specific areas.
• Is approximately symmetrical.
• Occurs mainly while awake.
• Decreases significantly during sleep.
• May occur in other family members.

Secondary hyperhidrosis:

Can result from a medical condition, medication or another physiological problem.

Sweating may be more generalized or may begin suddenly after previously normal sweating.

Depending on the child's symptoms, possible causes the clinician may consider include:

• Thyroid disorders.
• Hypoglycemia in selected circumstances.
• Certain infections or systemic illnesses.
• Some neurological conditions.
• Medications.
• Other medical conditions suggested by the child's history.

Not every child requires extensive laboratory testing.

Investigations are selected when the history or examination suggests a possible secondary cause.

Assessment begins with understanding the pattern of sweating and its effect on the child's daily life.

The clinician may ask about:

• The age symptoms began.
• Which body areas are affected.
• Whether sweating is symmetrical.
• Whether it occurs during sleep.
• Its effect on school, sport and daily activities.
• Other symptoms such as weight loss, palpitations, fever or fatigue.
• Current medications.
• Family history of similar excessive sweating.

A physical examination is then performed.

When symptoms are typical of primary focal hyperhidrosis and there are no signs suggesting another illness, special imaging or diagnostic tests are usually not required.

If features are unusual, laboratory testing or additional assessment may be used to look for a secondary cause.

Treatment usually begins with non-surgical approaches.

The choice depends on:

• The affected area.
• Severity.
• The child's age.
• Impact on daily life.
• Treatments already attempted.

Medical Antiperspirants:

Products containing aluminum salts can reduce sweat production by blocking sweat ducts.

They are commonly used as an initial treatment.

Skin irritation can occur, so appropriate application instructions should be followed.

Iontophoresis:

Iontophoresis uses a low electrical current passed through water to reduce sweating.

It is particularly useful for palmar and plantar hyperhidrosis.

Repeated treatments are generally needed initially, followed by maintenance sessions when effective.

Medication:

Anticholinergic medications may be used in selected patients to reduce stimulation of sweat glands.

Possible adverse effects can include:

• Dry mouth.
• Constipation.
• Blurred vision.
• Difficulty urinating.
• Other medication-specific effects.

These medicines should therefore be used under medical supervision.

Botulinum Toxin:

Botulinum toxin injections can temporarily reduce nerve stimulation of sweat glands in selected areas.

The effect is temporary and repeat treatment may be required.

Injections can also be uncomfortable, particularly when treating the palms or soles.

No single treatment is appropriate for every child, so management is individualized.

Surgery is not first-line treatment for hyperhidrosis.

It is considered only when a child has severe primary hyperhidrosis that significantly affects daily life and appropriate non-surgical treatments have failed to provide adequate control.

The surgical procedure is called Endoscopic Thoracic Sympathectomy or Thoracoscopic Sympathectomy, commonly abbreviated as ETS.

It is used particularly for carefully selected patients with severe palmar hyperhidrosis.

During the procedure, the surgeon uses a minimally invasive thoracoscopic approach to reach part of the sympathetic nerve chain inside the chest.

The nerve signals responsible for excessive sweating in the targeted region are interrupted.

The procedure can substantially reduce palmar sweating, but candidacy should not be based on sweating severity alone.

Assessment also considers:

• Impact on daily life.
• The child's age and maturity.
• Previous non-surgical treatments.
• Expectations of the child and family.
• Understanding of potential complications.

The most important potential consequence to discuss before sympathectomy is compensatory sweating.

After sweating is reduced in the targeted region, increased sweating may develop elsewhere on the body.

Possible areas include:

• Back.
• Abdomen.
• Chest.
• Legs.
• Other body regions.

The severity varies considerably between patients.

It may be mild and acceptable, or it may become significantly troublesome.

There is no way to guarantee before surgery that compensatory sweating will not occur.

Children and families should therefore understand that treating severe sweating in one region creates the possibility of increased sweating elsewhere.

This is one of the main reasons surgery is reserved for carefully selected patients after non-surgical treatment has been explored.

Like any thoracoscopic operation, sympathectomy has potential complications.

These may include:

• Postoperative pain.
• Bleeding.
• Air collecting around the lung, or pneumothorax.
• Anesthesia-related complications.
• Compensatory sweating.
• Excessive dryness of the hands.
• Less improvement than expected.
• Recurrence of sweating.
• Unintended injury to nearby nerves or tissues.
• Horner syndrome in rare circumstances if certain upper sympathetic nerves are affected.

The likelihood of individual complications varies with the operative level, technique and individual patient.

Potential benefits and risks should be discussed clearly before surgery is selected.

Before surgical treatment is considered, the team confirms that the child has primary hyperhidrosis suitable for surgery rather than excessive sweating caused by another medical condition.

Assessment reviews:

• When symptoms began.
• Areas involved.
• Severity of sweating.
• Effect on school, social life and activities.
• Non-surgical treatments already attempted.
• Current medications.
• Associated medical conditions.

Additional tests may be requested when there are features suggesting secondary hyperhidrosis.

Before surgery, the child and family should understand:

• The goal of surgery.
• Which areas are expected to become drier.
• That outcomes cannot be identical for every patient.
• The possibility of compensatory sweating.
• The possibility of persistent or recurrent sweating.
• Other surgical risks.
• Non-surgical alternatives.

Fasting and medication instructions before anesthesia should be followed, and the medical team should be informed if the child develops fever, infection or another new illness before surgery.

After thoracoscopic sympathectomy, the child is monitored to ensure stable breathing and circulation and adequate pain control.

Some discomfort at the small thoracoscopic incisions or inside the chest may occur during early recovery.

The surgical team determines when the child can return to:

• School.
• Normal daily activities.
• Sports.
• Normal bathing.

Parents should follow instructions regarding wound care, medication and activity.

The medical team should be contacted if the child develops:

• Difficulty breathing.
• Severe or increasing chest pain.
• Significant fever.
• Increasing redness, swelling or drainage from the incisions.
• Clear deterioration in general condition.
• Any sudden symptom that causes concern.

Follow-up assesses:

• Reduction of sweating in the targeted area.
• Excessive dryness.
• Development and severity of compensatory sweating.
• Effect of treatment on everyday activities.
• Any new symptoms.

Treatment success should be considered from the child's perspective and quality of life, not simply by measuring the amount of sweat.