What is the workup and treatment for a patient with nocturnal hyperhidrosis?

Workup for Nocturnal Hyperhidrosis

The comprehensive workup for nocturnal hyperhidrosis should focus on identifying underlying medical conditions through targeted history, physical examination, and laboratory testing, with treatment directed at the underlying cause when possible.

Initial Evaluation

Medical History Assessment

• Screen for "SCREeN" conditions that commonly cause nocturnal sweating 1:

  • Sleep disorders: obstructive sleep apnea, insomnia, restless legs syndrome
  • Cardiovascular: heart failure, hypertension
  • Renal: chronic kidney disease
  • Endocrine: diabetes mellitus, thyroid dysfunction, menopause
  • Neurological: autonomic dysfunction, Parkinson's disease

• Review current medications that may contribute to hyperhidrosis 1:

  • Diuretics, calcium channel blockers, antidepressants
  • Antiparkinsonian drugs
  • NSAIDs and other medications causing xerostomia

Key Screening Questions

• "Do you have problems sleeping aside from sweating at night?" 1
• "Have you been told that you gasp or stop breathing during sleep?" 1
• "Do you experience ankle swelling or shortness of breath?" 1
• "Do you get lightheaded when standing up?" 1
• "Do you have excessive thirst or frequent urination?" 1

Physical Examination

• Check for peripheral edema (fluid retention) 1
• Measure lying and standing blood pressure (orthostatic hypotension suggests autonomic dysfunction) 1
• Assess for signs of thyroid dysfunction 2
• Evaluate for neurological abnormalities (gait, tremor, speech) 1

Laboratory and Diagnostic Testing

First-Line Tests

• Complete blood count 2
• Comprehensive metabolic panel (electrolytes, renal function) 1
• Thyroid function tests (TSH, free T4) 2
• Hemoglobin A1c 1
• Serum calcium levels 1
• Vitamin D level 1, 2
• Iron studies (ferritin) 2

Second-Line Tests (Based on Initial Findings)

• For suspected sleep disorders:

  • Overnight oximetry or polysomnography 1
  • STOP-BANG questionnaire for OSA risk assessment 1

• For suspected cardiovascular disease:

  • Electrocardiogram 1
  • Brain natriuretic peptide (BNP) 1
  • Echocardiogram if BNP elevated 1

• For suspected endocrine disorders:

  • Morning urine osmolality after overnight fluid restriction 1
  • Parathyroid hormone level if hypercalcemia is detected 1

Treatment Approach

Addressing Underlying Causes

• Sleep disorders:

  • For obstructive sleep apnea: CPAP therapy 1
  • For restless legs syndrome: iron supplementation if ferritin <75 ng/ml 1

• Cardiovascular conditions:

  • Optimize heart failure management 1
  • Adjust timing of diuretic medications to morning rather than evening 3

• Endocrine disorders:

  • Treat thyroid dysfunction 2
  • Optimize diabetes management 1
  • Correct vitamin D deficiency if present 1

Symptomatic Management of Hyperhidrosis

First-Line Treatments

• Topical aluminum chloride solutions (10-20%) for focal hyperhidrosis 2, 4
• Environmental modifications:
  • Moisture-wicking bedding and sleepwear 2
  • Maintaining cool bedroom temperature 2
  • Avoiding triggers (spicy foods, caffeine, alcohol) 2

Second-Line Treatments

• Oral glycopyrrolate (1-2 mg once or twice daily) 2, 4
• Oral anticholinergics (monitor for side effects including dry mouth, blurred vision, urinary retention) 4, 5

Advanced Treatments (for Severe Cases)

• Botulinum toxin injections for focal hyperhidrosis 2, 4
• Iontophoresis for palmar/plantar hyperhidrosis 4, 5

Special Considerations

• Nocturnal hyperhidrosis is often multifactorial, requiring a comprehensive approach 1
• Elderly patients with cognitive impairment may need additional safety measures to prevent falls when getting up at night due to sweating 3
• Treatment should be tailored based on severity using validated tools such as the Hyperhidrosis Disease Severity Scale 6

Common Pitfalls

• Failing to distinguish between primary focal hyperhidrosis and secondary generalized hyperhidrosis 7, 6
• Overlooking medications as potential causes of nocturnal sweating 1
• Not considering serious underlying conditions like malignancy in cases of unexplained night sweats 1
• Assuming a link between a medical condition and hyperhidrosis without establishing clear causation 1