What is the workup for a patient who reports diaphoresis (excessive sweating)?

From the Guidelines

A patient who reports diaphoresis (excessive sweating) should undergo a thorough evaluation including a complete medical history, physical examination, and targeted laboratory tests, prioritizing the identification of underlying conditions that may impact morbidity, mortality, and quality of life. Begin with thyroid function tests (TSH, free T4) to rule out hyperthyroidism, complete blood count to check for infection or malignancy, and fasting blood glucose to exclude diabetes 1. Consider checking serum catecholamines if pheochromocytoma is suspected, particularly if sweating is accompanied by hypertension and palpitations. A detailed medication review is essential as many drugs can cause sweating as a side effect, including antidepressants, opioids, and certain antihypertensives. Document the pattern of sweating (generalized vs. localized), triggers, timing, and associated symptoms. For localized hyperhidrosis, the starch-iodine test can help identify affected areas. If night sweats are prominent, consider tuberculosis testing or other infectious disease workup. The evaluation should be tailored based on accompanying symptoms, as sweating can be a manifestation of numerous underlying conditions including infections, malignancies, endocrine disorders, neurological conditions, or primary hyperhidrosis.

Some key considerations in the workup include:

• Identifying potential drug-induced causes of sweating, as withdrawal of certain drugs may be associated with fever, tachycardia, diaphoresis, and hyperreflexia 1
• Ruling out conditions such as malignant hyperthermia and neuroleptic malignant syndrome, which can have devastating consequences if left untreated 1
• Considering the patient's medical history and physical examination findings to guide the selection of targeted laboratory tests
• Being aware of the potential for sweating to be a symptom of underlying conditions that may impact morbidity, mortality, and quality of life, such as cystic fibrosis, which can be diagnosed with a sweat chloride test 1

Treatment will depend on the identified cause but may include antiperspirants, anticholinergic medications, iontophoresis, botulinum toxin injections, or addressing the underlying condition. It is essential to prioritize the patient's morbidity, mortality, and quality of life when determining the best course of treatment.

From the Research

Diagnosis and Treatment Approach

The workup for a patient who reports diaphoresis (excessive sweating) involves a comprehensive approach to diagnose and manage hyperhidrosis. The following steps can be taken:

• Identify the type of hyperhidrosis: primary or secondary, and its location (axillae, palms, soles, or craniofacial region) 2, 3, 4
• Use the Hyperhidrosis Disease Severity Scale to grade the tolerability of sweating and its impact on quality of life 2
• Initial treatment options:
  • Topical aluminum chloride solution for primary focal hyperhidrosis 2
  • Topical glycopyrrolate for craniofacial sweating 2
  • Antiperspirants as the first-line therapy for primary focal hyperhidrosis 3
  • Iontophoresis for palmar and plantar hyperhidrosis 2, 3, 5
• Second-line treatment options:
  • Botulinum toxin injections (onabotulinumtoxinA) for axillary, palmar, plantar, or craniofacial hyperhidrosis 2, 3, 4
  • Oral anticholinergics for severe cases of hyperhidrosis when other treatments fail 2, 5
• Other treatment modalities:
  • Local microwave therapy for axillary hyperhidrosis 2
  • Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency 3, 5
  • Local surgery and endoscopic thoracic sympathectomy for severe cases of hyperhidrosis that have not responded to topical or medical therapies 2, 3, 6

Treatment Algorithm

A stepwise approach to investigating and treating patients with hyperhidrosis can be taken, considering the location and severity of the condition 5, 6. This approach may involve a combination of topical, medical, and surgical therapies to manage the symptoms and improve the patient's quality of life.