What is the diagnosis and treatment for a 37-year-old female presenting with chronic hyperhidrosis (excessive sweating) and anxiety?

From the Guidelines

For this 37-year-old female with chronic hyperhidrosis and anxiety, I strongly recommend addressing her anxiety first with cognitive behavioral therapy (CBT) as it can help alleviate both conditions. The most recent and highest quality study, 1, suggests that for a patient with moderate symptoms of anxiety, clinicians should offer individual or group therapy with CBT, behavioral activation (BA), structured physical activity and exercise, or psychosocial interventions with empirically supported components.

Anxiety Management

• CBT is a highly effective treatment for anxiety and can be used in conjunction with other treatments for hyperhidrosis.
• Behavioral activation (BA) and structured physical activity can also be beneficial for anxiety management.
• Psychosocial interventions with empirically supported components, such as relaxation and problem-solving, can also be effective.

Hyperhidrosis Management

• Once anxiety is being addressed, hyperhidrosis can be managed with topical treatments such as aluminum chloride antiperspirants (20-25% concentration) applied nightly to dry skin.
• If topical treatments are insufficient, oral anticholinergics like glycopyrrolate (1-2mg twice daily) or oxybutynin (5-10mg daily) can be considered, though side effects should be monitored.
• For localized hyperhidrosis, botulinum toxin injections (50-100 units per axilla) can provide 4-6 months of relief.
• Iontophoresis (20-30 minute sessions, 3 times weekly initially, then maintenance) is effective for palmar/plantar hyperhidrosis.

Importance of Addressing Both Conditions

• The connection between hyperhidrosis and anxiety creates a vicious cycle where each condition exacerbates the other, so addressing both simultaneously is crucial for optimal management.
• By addressing anxiety first with CBT, as recommended by 1, we can potentially alleviate some of the symptoms of hyperhidrosis and improve the patient's overall quality of life.

From the FDA Drug Label

PAXIL is a prescription medicine used to treat depression It is also used to treat: Major Depressive Disorder (MDD) Obsessive Compulsive Disorder (OCD) Panic Disorder Social Anxiety Disorder Generalized Anxiety Disorder (GAD) Posttraumatic Stress Disorder (PTSD)

The patient is a 37-year-old female with Chronic Hyperhidrosis and Anxiety.

• Paroxetine (PAXIL) is used to treat Generalized Anxiety Disorder (GAD), which may be relevant to the patient's anxiety.
• However, there is no direct information in the drug label that supports the use of paroxetine (PAXIL) for Chronic Hyperhidrosis.
• Sertraline is also used to treat Social Anxiety Disorder, Panic Disorder, PTSD, and OCD, which may be relevant to the patient's anxiety.
• But, similar to paroxetine (PAXIL), there is no direct information in the drug label that supports the use of sertraline for Chronic Hyperhidrosis. Given the information provided in the drug labels, paroxetine (PAXIL) or sertraline may be considered for the treatment of the patient's anxiety, but not specifically for Chronic Hyperhidrosis 2 3.

From the Research

Treatment Options for Hyperhidrosis

• Topical aluminum chloride hexahydrate is a common treatment for primary focal hyperhidrosis, and can be used in combination with botulinum toxin type A for moderate to severe cases 4.
• Botulinum toxin injection is considered a first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis 5.
• Iontophoresis is a primary remedy for palmar and plantar hyperhidrosis, and can be used in combination with other treatments 5, 6.
• Oral anticholinergics and local microwave therapy are also options for treating hyperhidrosis, particularly in severe cases 5, 6.

Relationship between Hyperhidrosis and Anxiety

• Hyperhidrosis can have a significant impact on a patient's quality of life, resulting in social and work impairment and emotional distress 5.
• There is an association between primary focal hyperhidrosis and anxiety, as well as depressive syndromes 7.
• Treatment with botulinum toxin A has been shown to lead to a marked reduction in social phobia, anxiety, and depression, and increased quality of life in patients with primary focal hyperhidrosis 7.
• Hyperhidrosis is frequently seen in patients with social anxiety disorder, and its response to treatment is variable 8.

Management of Hyperhidrosis

• The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life, and can be used to guide treatment 5.
• A sequenced approach to treatment, starting with lifestyle and behavioral recommendations and progressing to more invasive treatments as needed, is recommended 6.
• Surgery may be considered when more conservative treatments have failed, but is generally considered a last resort due to the risk of secondary compensatory hyperhidrosis 6.