A 21-year-old woman comes to the office due to excessive sweating. She reports heavy axillary sweating even when she is not feeling warm. The patient has had no anxiety, tremors, or weight changes. Her symptoms began several years ago and have become progressively worse. The patient has tried a variety of over-the-counter antiperspirants without relief, and her clothes often become stained, causing significant embarrassment at her job. Medical history is otherwise unremarkable. She drinks alcohol on social occasions and does not use tobacco or illicit drugs. Her only medication is an oral contraceptive.
Vital signs are within normal limits and physical examination shows no abnormalities.
Which of the following is the most appropriate next step in management of this patient?

Question

A 21-year-old woman comes to the office due to excessive sweating.  She reports heavy axillary sweating even when she is not feeling warm.  The patient has had no anxiety, tremors, or weight changes.  Her symptoms began several years ago and have become progressively worse.  The patient has tried a variety of over-the-counter antiperspirants without relief, and her clothes often become stained, causing significant embarrassment at her job.  Medical history is otherwise unremarkable.  She drinks alcohol on social occasions and does not use tobacco or illicit drugs.  Her only medication is an oral contraceptive.
Vital signs are within normal limits and physical examination shows no abnormalities.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9797_374f_853d_fdef13630f00_MD0002_00 Hyperhidrosis is excessive sweating beyond that needed for normal thermoregulation. It most commonly affects the axillae, face, and palms/soles and can lead to significant patient distress and embarrassment. Most cases are bilateral and idiopathic (primary hyperhidrosis). Primary hyperhidrosis usually becomes symptomatic before age 25, and patients often have a family history of similar symptoms. Unlike night sweats seen in infectious and inflammatory disorders, the sweating in primary hyperhidrosis does not persist during sleep. For patients with typical features and without symptoms to suggest an underlying metabolic or inflammatory disorder, diagnostic testing is not needed. Most patients can be managed with topical aluminum chloride solution. Treatment is initially applied nightly, but as symptoms improve, it can be applied less often. If symptoms are confined to the palms and soles, iontophoresis (application of an electrical current, usually in a device containing tap water) is an effective alternative. If first-line treatment is ineffective, injection of botulinum toxin can be considered (Choice D). Anticholinergic medications (eg, glycopyrrolate, oxybutynin) can be used for systemic therapy but are associated with more significant side effects. (Choice A) Given this patient's chronic course and lack of specific anxiety symptoms, anxiolytic medication is not indicated. In addition, selective serotonin reuptake inhibitors (eg, fluoxetine) and other antidepressant medications are a common cause of secondary hyperhidrosis. (Choice B) Selective estrogen receptor modulators (eg, raloxifene) can cause sweating. In natural menopause, sudden discontinuation of estrogen-based therapy can cause sweating and hot flashes, but routine use of oral contraceptives does not cause hyperhidrosis. (Choice C) Common systemic disorders that can cause secondary hyperhidrosis include hyperthyroidism, malignancy, chronic infections (eg tuberculosis), and chronic heart or lung disease. Hyperhidrosis can also be seen in patients with excessive alcohol use or opioid withdrawal. However, this patient has no features to suggest a secondary cause of sweating. Educational objective: Hyperhidrosis is excessive sweating beyond that needed for normal thermoregulation. It most commonly affects the axillae, face, and palms/soles. Most cases are bilateral and idiopathic (primary hyperhidrosis). The majority of patients can be managed with topical aluminum chloride solution. __________ References: Hyperhidrosis. (http://www.ncbi.nlm.nih.gov/pubmed/29083676)

A 21-Year-Old Woman Comes to the Office Due to Excessive