Palmar Hyperhidrosis - Sweaty Hands

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Hyperhidrosis and Facial Blushing


- Hyperreactivity of the Sympathetic Nervous System -

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Palmar Hyperhidrosis - Sweaty Hands


Palmar hyperhidrosis

Manifestations

Palmar hyperhidrosis is a peculiar condition characterized by excessive sweating of the hands, in most cases combined with severe sweating of the feet, and is therefore often referred to as palmo-plantar hyperhidrosis.
The degree of sweating varies and may range from moderate moisture to dripping, it may be a constant condition (ceasing only while sleeping or at rest) or appear, quite suddenly, under certain circumstances.
Palmar hyperhidrosis
It may be triggered by high outside temperatures or emotional stress, but it can also appear without any obvious reason. Generally, it worsens during the warm season and improves somewhat under cold weather conditions. Most patients notice that their hands not only become moist/wet, but also cold, the reason for this being twofold: the evaporating sweat withdraws heat energy from the underlying skin surface and the overactive sympathetic nervous system causes contraction of the peripheral vessels leading to reduced microcirculation in the hands (feet). The hands often assume a bluish-reddish hue.

Occurrence and course

In about 1% of the population suffer from sweaty palms, about 0.2% from very serious hyperhidrosis.
Characteristically, the classical form of palmar hyperhidrosis starts in most cases already in childhood and is generally combined with plantar hyperhidrosis, whereas other types of hyperhidrosis have their onset later in life. In the school child, the sweaty palms and fingers may cause difficulties when writing and during other manual activities, but frequently the psychosocial distress begins in adolescence. The youngster becomes conscious of and embarrassed for his "handicap", avoids direct physical contact with others and, frequently, tries to hide the hands or even avoid social contacts alltogether. For many the condition imposes restrictions regarding their choice of profession, e.g. because unable to manipulate materials sensitive to humidity (paper etc) or because reluctant to customer contact where activities like shaking hands are necessary routines. Against common belief, the sweating does not improve with age, though the individual may "get used" to it and adapts his/her habits to the condition.

Causes

This type of focal hyperhidrosis is almost always of genetic origin and rarely caused by underlying diseases (e.g. neurological conditions). Over 25% of the affected individuals have a family history of excessive sweating.

Assessment

A typical case of palmar (or palmo-plantar) hyperhidrosis does not need any assessment: the diagnosis can be made on the base of anamnestical data (early onset in life in an otherwise healthy individual, characteristic distribution). Assessment may only be required if excessive sweating starts later in adulthood or if the symptoms appear assymetrically (neurological condition?).

Treatment

A stepwise approach is recommended, though experience teaches that severe variants of hyperhidrosis (wet and/or dripping palms or fingers) will probably not be satisfactorily treated but with surgery.

  • Antiperspirants:
    Aluminum chloride solutions must be applied at night when sweating is absent, in order to be absorbed. Prolonged use may lead to thickening of the skin or other tissue reactions (eczema) which may require interrupting or suspending the treatment.
  • Iontophoresis:
    a valid alternative for low to medium grade hyperhidrosis when antiperspirants fail. Requires frequent periodic treatments (e.g. 20 minutes every 1 or 2 days).
  • Sympathetic Surgery:
    In severe palmar hyperhidrosis, Endoscopic Transthoracic Sympathectomy delivers immediate and excellent results in all patients in whom the procedure can be carried out, and it is for these patients the only way, not only to get some improvement, but to eliminate the problem definitively. The T3 ETS will cope with concomitant axillary hyperhidrosis as well, if present.
    Patients with palmar hyperhidrosis who have acquired severe compensatory hyperhidrosis of the trunk after ETS have almost always been operated at the T2 level. Therefore, in order to reduce the level of side effects, especially to prevent extreme compensatory sweating, the procedure should be limited to the T3 ganglion, avoiding the T2 ganglion by any means. Unfortunately, a procedure declared as T3-operation frequently is performed in a way that collateral damage occurs on the T2 ganglion, leading to the faulty conclusion that T3 operations and T2 operations carry the same risk.
Botulinum toxin is not recommended for treatment of handsweat because of a series of shortcomings. The application consists of 40-80 injections per hand which makes it a rather painful procedure and may, by most, not be tollerated without local anestesia (block of the median and ulnar nerve and infiltration of the superficial radial branch of the radial nerve at the level of the wrist). Superficial portions of the thenar and hypothenar muscles (muscles acting on the thumb and little finger) may be paralyzed resulting in weakening of the grip for a couple of weeks following the procedure. In some cases, repeated treatments have lead to permanent weakness even after the botulinum injections have been suspended. The effect of the treatment is often incomplete and lasts only for a few months (average 3-5 months) which makes the cost of the method unsustainable in the long run (treating both hand doubles the cost, obviously, since each hand requires 1 vial, e.g. 100 U of Botox per hand).