COEUR D’ALENE, IDAHO – An individual who complains of excessive focal sweating that continues during sleep does not – repeat, not – have primary focal hyperhidrosis, according to pediatric dermatologist Dr. Jane S. Bellet.
"If you remember nothing else I tell you today, the sweating must cease during sleep. This is absolutely critical. Otherwise you’re dealing with something completely different. So I really press every single patient on that question," she emphasized at the annual meeting of the Society for Pediatric Dermatology.
Dr. Jane S. Bellet
Primary focal hyperhidrosis occurs in 1.6% of children and adolescents. Two-thirds of affected patients have a positive family history.
"This is really a life-altering condition, and if untreated it will continue unabated into adulthood. There are effective treatment options. We can make a profound difference for these children and adolescents," she said.
Primary focal hyperhidrosis is a clinical diagnosis. It’s based upon the patient’s history, a review of symptoms, and physical examination. No tests are needed, although Minor’s starch iodine test or the older quinizarin test can be useful as documentation for insurance purposes or to guide botulinum toxin A therapy, according to Dr. Bellet of Duke University, Durham, N.C.
According to the widely accepted, decade-old diagnostic criteria developed by a multispecialty expert working group, the diagnosis requires visible, excessive, focal sweating of the axillae, palms, soles, or face/head for at least 6 months with no apparent cause, plus at least two of six additional criteria. These are onset before age 25 years; bilateral, relatively symmetric sweating; impairment of daily activities; cessation during sleep; a positive family history for the disorder; and at least one episode per week (J. Am. Acad. Dermatol. 2004;51:274-86).
Sweating that continues during sleep is due to one of many possible secondary causes, which are elaborated upon in the multispecialty working group’s report.
"It’s a completely separate algorithm, but if you’re dealing with secondary hyperhidrosis there will always be clues that will send you down that pathway," she said.
The patient history is critical in establishing the diagnosis of primary focal hyperhidrosis and its adverse effect on quality of life and daily activities, which is important to document for insurance purposes.
The physical exam is "pretty basic," according to Dr. Bellet. She uses it as an opportunity to touch the patient and establish a bond.
"Shake hands. It shows the patient you understand their condition, and you know their embarrassment. Resist the temptation to wipe your hands on your pants afterward," she advised.
The review of symptoms is essentially a screen for secondary causes of hyperhidrosis to make sure that the correct diagnosis is indeed primary focal hyperhidrosis. Fever, headache, weight loss, abdominal pain, vomiting, palpitations, anorexia – these point toward a secondary cause. Medications that can cause a generalized sweating problem include antidepressants, antimigraine medications, beta-agonists, pilocarpine, insulin, and GnRH agonists.
Dr. Bellet reported having no financial conflicts of interest regarding her presentation.