Need Help for Hyperhidrosis? No Sweat!

I have a 45-year-old patient who sweats constantly and severely, whether at rest or at work. He recently had valve repair for idiopathic hypertrophic subaortic stenosis, and he feels that the sweating has worsened since then. Results of laboratory screenings for thyroid hormone and electrolyte levels, a complete blood cell count, and a chemistry panel are all normal; he takes no medications. He has recurring intertriginous tinea as a result of the constant wetness. Do you have any suggestions for how to help this patient?
— MD

Excessive sweating, or hyperhidrosis, can be primary or secondary. Cardiac disease can cause hyperhidrosis. If the results of his laboratory workup are normal and he does not show evidence of leukemia, lymphoma, infection, or diabetes, then I would try treating him for primary hyperhidrosis.

If the sweating is diffuse, an oral anticholinergic may be of some help. I usually use glycopyrrolate, 1 mg bid, and increase the dose every few weeks until the sweating decreases or until an adverse effect develops. Obviously, you will need to check for any drug-drug interactions or contraindications before beginning such a regimen. Other oral agents that have occasionally been reported to be effective in excessive sweating are clonidine and propranolol; one of these might be a consideration, given your patient's cardiac history.

If the sweating is more localized—to just his groin area—you can try systemic therapy or use a more focal treatment. Topical aluminum chloride, either 10% (available over-the-counter) or 20% (a prescription-only strength), can be applied every night to a dry area and washed off in the morning. During the daytime, recommend that he use powders and absorbent clothing. In addition, botulinum toxin can be used off-label for nonaxillary hyperhidrosis. In general, groin sweating is a difficult problem to treat.

— Dee Anna Glaser, MD
  Professor and Vice Chairman, Department of Dermatology
  Director of Cosmetic & Laser Surgery
  Saint Louis University
  St Louis