Hyperhidrosis, Anhidrosis and Bromhidrosis

Outline the possible aetiological factors and describe the clinical signs and symptoms of hyperhidrosis affecting an adolescent male.  And outline the management strategies.DefinitionHyperhidrosis is excessive sweat production.  It can affect the whole body or certain parts of the body.  For example, the plantar surface of the foot, the palms of the hands and the armpits.CauseThe primary cause of hyperhidrosis is an abnormality of the sympathetic nervous system.  Possible secondary factors include hyperthyroidism, eating hot/spicy foods (‘gustatory’), being drunk on alcohol or being high on drugs such as cocaine or ecstasy, stress or anxiety and certain medication such as anti-depressants.Clinical signsClinical signs of hyperhidrosis include visible beads of sweat on the skin (plantar surface of the foot), interdigital maceration, socks saturated with moisture, sweat stains on footwear and signs of rotting inside footwear.  The skin loses its elasticity which can result in interdigital fissures and blisters.  In addition the skin is less resistant to bacterial and fungal infections, and if bacteria is allowed to be present on the skin, this can mix with the sweat causing a malodour (Bromhidrosis). The young male may be distressed and embarrassed by the condition, and may not socialise much for fear of the condition becoming visible to others.  He may lack confidence.Management strategyIdentify the cause - avoid triggers such as spicy food and alcohol.  Use antiperspirants with aluminium chloride solution, and astringents such as surgical spirit.  Footbaths with tepid/warm water or potassium permanganate or epsom salts could be used.  Socks should be changed daily or more frequently.  Hoisery should be made of cotton or wool.  Leather, cotton or Goretex shoes should be worn.  Footwear should be rotated and shoes should be allowed to dry for 24 hours before being worn again. Sandals should be worn in warm weather.  Additional treatments include Iontophoresis, Botox injections and a Sympathectomy.Iontophoresis involves placing the feet in a bowl of water and a weak electric current is passed through the water.  The current is thought to help block the sweat glands.  Each session of Iontophoresis lasts between 20-30 minutes and two to four sessions are required each week.  This treatment has proved to be effective in 80 to 90% of cases.Botox is a powerful protein which is injected around 12-45 times in the affected area.  The procedure takes about 30-45 minutes.  The toxin works by blocking the signals from the brain to the sweat glands, reducing the amount of sweat that is produced.  The effects last from 2-8 months.  There is limited availability on the NHS.A Sympathectomy selectively destroys the parts of the sympathetic chain that supply the sweat glands.Outline the possible aetiological factors and describe the clinical signs and symptoms of bromhidrosis affecting an adolescent male.  And outline the management strategies.DefinitionBromhidrosis is the action of bacteria on hyperhidrotic skin.  It is characterised by excessive, usually unpleasant odour.  This is largely due to bacterial breakdown of apocrine gland secretions, yielding ammonia and fatty acids.  Hyperhidrotic skin is caused by an abnormality in the sympathetic nervous system.  Secondary causes of hyperhidrosis include hyperthyroidism, eating hot/spicy foods (‘gustatory’), being drunk on alcohol or being high on drugs such as cocaine or ecstasy, stress or anxiety and certain medication such as anti-depressants.Clinical signsClinical signs of bromhidrosis include visible beads of sweat on the skin (plantar surface of the foot), interdigital maceration, socks saturated with moisture, sweat stains on footwear and signs of rotting inside footwear.  The skin loses its elasticity which can result in interdigital fissures and blisters.  In addition the skin is less resistant to bacterial and fungal infections.  Unpleasant odour.The young male may be distressed and embarrassed by the condition, and may not socialise much for fear of the condition becoming visible to others.  He may lack confidence.Management strategyIdentify the cause - avoid triggers such as spicy food and alcohol.  Use antiperspirants with aluminium chloride solution, and astringents such as surgical spirit.  Footbaths with tepid/warm water or potassium permanganate or epsom salts could be used.  Socks should be changed daily or more frequently.  Hoisery should be made of cotton or wool.  Leather, cotton or Goretex shoes should be worn.  Footwear should be rotated and shoes should be allowed to dry for 24 hours before being worn again. Sandals should be worn in warm weather.  Additional treatments include Iontophoresis, Botox injections and a Sympathectomy.Iontophoresis involves placing the feet in a bowl of water and a weak electric current is passed through the water.  The current is thought to help block the sweat glands.  Each session of Iontophoresis lasts between 20-30 minutes and two to four sessions are required each week.  This treatment has proved to be effective in 80 to 90% of cases.Botox is a powerful protein which is injected around 12-45 times in the affected area.  The procedure takes about 30-45 minutes.  The toxin works by blocking the signals from the brain to the sweat glands, reducing the amount of sweat that is produced.  The effects last from 2-8 months.  There is limited availability on the NHS.A Sympathectomy selectively destroys the parts of the sympathetic chain that supply the sweat glands.ESSAY PLAN - Definition (and where), Causes, Clinical signs, Management strategy.Discuss the possible causes of anhidrosis (complicated with heel fissures) in a 50 year old female and identify the possible clinical features and outline your management strategyAnhidrosis occurs when the sweat glands stop working.  Conditions where there is autonomic nerve damage can also cause anhidrosis.  For example, diabetes, alcoholism and Parkinson's disease.  Other medical conditions such as Peripheral neuropathy, Peripheral vascular disease and Hypothyroidism can also cause this condition.  In addition skin damage such as clogged sweat ducts and severe burns can adversely affect the production of sweat.  Certain medications and dehydration can also lead to anhidrosis.  Anhidrosis can be confused with a fungal infection such as tinea pedis.Risk factors for anhidrosisIncreased age can reduce the ability to sweat normally, this is usually due to issues with temperature regulation.  Excessive washing can lead to dry skin.  Skin disorders such as psoriasis, heat rash and scleroderma can affect the sweat glands.  Genetic abnormalities can also lead to disorders that affect the sweat glands.Clinical FeaturesDry, scaly, rough skin.  This reduces tissue viability and weakens the integrity of the skin.  It is inelastic and there may be fissures present.  These commonly occur around the heel and can be the result of excessive tensile stress.Management plan The aim is to restore skin integrity and elasticity, and reduce desquamation and flaking.  In addition, we need to prevent fissuring and this can be done with the use of silicone heel pads.  Callous and seed corns should be removed from the affected area.  Any fungal infection should be eliminated.  Nails should be cared for.  The patient should avoid sandals or sling back shoes.  Passive/plain and active emollients should be used.  An emollient footbath could also be used.  If required the patient should be referred to the dermatology department.Passive/Plain emollients prevent loss of moisture from the skin.  For example, E45 .  Active emollients contain ingredients that attract moisture to the skin, for example, urea.Management plan for fissuresFor a dry fissure, the cause needs to be established.  Strict antiseptic precautions must be taken before the surrounding callus is debrided.  A sterile dressing should be applied if appropriate. Skin and footwear advice should be given.  It may be appropriate to refer the patient to the dermatology department.  A biomechanical examination could also be undertaken to establish if there are any mechanical issues with the foot. For a moist fissure, the cause should be established.  The callus should be debrided under strict antiseptic precautions.  Advice should be given re hyperhidrosis.  Astringent liquids should be applied to the area, rather than creams.  Antifungal therapy should be given if appropriate.ESSAY PLAN - Definition, Causes (medical and other).  Risk factors, Clinical features, Management plan and Management plan for fissures.

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