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Bromihdrosis PDF
Bromihdrosis PDF
Hyperhidrosis and
Eshini Perera
Rodney Sinclair
bromhidrosis
A guide to assessment and management
266 Reprinted from Australian Family Physician Vol. 42, No. 5, may 2013
Conversely, focal hyperhidrosis involves specific sites of the body, A distinction between generalised and focal hyperhidrosis should
most commonly the axilla, palms and soles. Focal hyperhidrosis occurs be made at the initial assessment. The medical history should be
in otherwise healthy patients commonly before the age of 25 years,5 concentrated on:
and roughly two-thirds of patients report a positive family history.1 • location of sweating: general or specific area, unilateral or
The most common cause of focal hyperhidrosis is primary idiopathic symmetrical areas
hyperhidrosis; causes are outlined in Table 3. It is important to note • duration of presentation
that primary hyperhidrosis ceases when sleeping, in contrast to night • family history of focal hyperhidrosis
sweats, which can indicate a serious underlying disorder. • age of onset
• concurrent medical illnesses
Table 1. Causes of generalised hyperhidrosis • triggers of sweating including anxiety, chewing, eating, temperature.
• Endocrine diseases A diagnosis of idiopathic focal hyperhidrosis can be made on history if
– menopause* the patient is noted to have excessive visible sweating for at least 6
– hyperthyroidism* months and two of the following:
– diabetes** • bilateral symmetrical sweating
– hypoglycaemia** • impairment of daily activities
– pheochromocytoma*** • at least one episode per week
– hyperpituitarism*** • onset before 25 years of age
– carcinoid syndrome***
• positive family history
• Medications*
• focal sweating that ceases during sleep.
– propranolol
If there is no obvious underlying cause on history and examination, and
– tricyclic antidepressants
the presentation is characteristic for primary focal hyperhidrosis, then
– cholinesterase inhibitors
further investigations are not required.
– selective serotonin reuptake inhibitors
– opioids
Assessment and diagnosis of
• Febrile infective illness**
bromhidrosis
– malaria
– tuberculosis While Staphylococcus, Micrococcus, Corynebacterium and
– endocarditis Propionibacterium can be commonly isolated from the resident
– HIV (seropositive patients) microflora in people affected by bromhidrosis, bacterial swabs are
• Congestive heart failure** unlikely to be useful in guiding management.
• Neurological disorders** Triethylaminuria is a rare inborn error of metabolism leading to a
– Parkinson disease distinctive fishy odour.6 Genetic testing is available in Australia, and
– peripheral neuropathies the condition can be corrected by dietary modification.
– brain lesions (eg. malformation of corpus callosum)
• Malignancy*** Management of hyperhydrosis
* Uncommon Conservative treatment measures have usually been tried and
** Very uncommon failed by the time the patient consults their GP. There are a number
*** Rare of surgical and non-surgical treatments for focal hyperhidrosis.
Management of generalised hyperhidrosis, on the other hand, involves
Table 2. Investigations that may be considered addressing the underlying cause.
for late onset, recent onset or very severe
hyperhidrosis Topical therapies for focal hyperhidrosis
• Blood tests Aluminium compounds
– full blood count
– electrolytes and renal function tests While most standard supermarket antiperspirants contain aluminium
– liver function tests chloride, higher potency agents may contain aluminium chlorohydrate.
– thyroid function tests Aluminium chloride hexhydrate is significantly more effective again,
– HIV serology and should be the first line of therapy. Antiperspirants containing
– fasting blood glucose level aluminium chloride hexhydrate are sold in pharmacies; a prescription is
• Testing for specific infectious diseases as suggested not required. All of these agents have a common mechanism of action
by the history (eg. tuberculosis) that involves the mechanical obstruction of the eccrine gland duct,
• 24 hour urinary catecholamines which in turn leads to atrophy of the eccrine acini.7
Reprinted from Australian Family Physician Vol. 42, No. 5, may 2013 267
FOCUS Hyperhidrosis and bromhidrosis – a guide to assessment and management
Iontophoresis
Iontophoresis is a specialised treatment only available in some
states. It utilises a delivery system for small polar molecules into
the skin (Figure 1). Figure 2 and Figure 3 provide a visual comparison
for the effectiveness of this therapy. The most effective chemical
for hyperhidrosis is glycopyrrolate. Tap water is much less effective,
although there are iontophoresis devices available for home use.10
Botulinum toxin A
Botulinum toxin A is a highly effective treatment for focal hyperhidrosis.
The main mechanism of action is the inhibition of acetylcholine release
from the sympathetic nerves that innervate the eccrine sweat glands.11 Figure 2. The starch-iodine test. Iodine is applied to a dry
Medicare subsidises the use of botulinum toxin A for severe primary area of skin and starch is sprinkled on top. The iodine,
axillary hyperhidrosis in patients aged 12 years or more who have failed starch and sweat react to form the dark sediment. The left
palm has not yet been treated with iontophoresis
or are intolerant to topical aluminium chloride hexahydrate after 1–2
268 Reprinted from Australian Family Physician Vol. 42, No. 5, may 2013
Hyperhidrosis and bromhidrosis – a guide to assessment and management FOCUS
Summary
Both hyperhidrosis and bromhidrosis are common and potentially
distressing conditions. Sensitive management and appropriate
referral may help minimise the impact on the patient’s quality of life
at both a social and functional level.
Authors
Eshini Perera MBBS, BMedSc, is a Masters candidate, Department of
Dermatology, Epworth Hospital, Melbourne, Victoria. eshinip@gmail.
com
Rodney Sinclair MBBS, MD, FACD, is Professor of Dermatology,
University of Melbourne and Director of Dermatology, Epworth
Hospital, Melbourne, Victoria.
Reprinted from Australian Family Physician Vol. 42, No. 5, may 2013 269