Patient Presentation
A 9 month-old male came to clinic for his health supervision visit.
His parents had no complaints but when discussing sleeping they asked why his head always seemed sweaty at night.
Originally they thought that he was overdressed, but even with different temperatures or clothing his head always sweats at night.
They report that he occasionally does this during naps also, but not when awake. He is afebrile and the rest of his body does not seem to sweat during these episodes. He others apepars to sweat normally when exposed to excessive heat or if febrile.
His past medical history, family history and review of systems are all negative.
The pertinent physical exam shows a developmentally appropriate male with growth parameters in the 75-90% and normal growth curves.
His physical examination was unremarkable.
The diagnosis of idiopathic hyperhidrosis of the scalp was made. The pediatrician told the parents that this is fairly common but the cause is unknown.
As the patient had an otherwise normal history and physical examination the pediatrician recommended monitoring and to call if the sweating occurs at other times, changes or new symptoms occur.
The patient’s clinical course over the next 5 years showed almost nightly hyperhidrosis of the scalp but the child continued to grow and develop normally.
Discussion
Sweating is made by the eccrine glands and is a normal physiologic response that helps to maintain body temperature.
Hyperhidrosis is sweating beyond what is needed to maintain normal temperature regulation.
It can be primary or secondary, and generalized, regional or focal, regional.
Some studies report a prevalence of 1-2.8%, but this may be underreported.
Hyperhidrosis can be not only socially a problem, but may not allow people to have careers in areas that contact paper, metal or electrical components.
Hyperhidrosis can also damage clothing, shoes and furniture too.
Sweating around the head particularly during sleep is a common finding especially in children. The cause is not understood.
Sweating of the palms and soles is also common particularly if in a stressful situation or if in an enclosed environment (i.e. shoes, coat pockets, etc.).
Axillary sweating is often caused by anxiety and thermal stimuli.
Treatment for hyperhidrosis includes many options depending on the location, potential cause, and severity.
Topical treatments include antiperspirants, tannic acid, formalin, glutaraldyde and anticholinergics.
System treatment includes anticholinergics, botulinum toxin, calcium-channel blockers, clonidine, and non-steroidal antiinflammatory drugs.
Surgical treatment includes excision of axillary sweat glands, liposuction, and sympathectomy.
Electrical treatment includes iontophoresis.
Learning Point
The causes of hyperhidrosis include:
- Endocrine
- Acromegaly
- Diabetes mellitus
- Gout
- Hyperpituitarism
- Hypoglycemia
- Menopause – secondary
- Thyrotoxicosis
- Environment (most common)- heat illnesses, elevated humidity, exercise
- Dermatologic
- Eccrine nevus
- Drugs
- Alcohol
- Amitriptyline
- Amphetamine
- Antihistamine
- Ephedrine
- Haloperidol
- Methylphenidate
- Propanolol
- Phenothiazine
- Physostigmine
- Pilocarpine
- Drug withdrawal
- Fever
- Infections, acute and chronic
- Genetic
- Episodic spontaneous hypothermia with hyperhidrosis
- Familial dysautononia (i.e. Riley-Day syndrome)
- Idiopathic
- Primary or essential hyperhidrosis
- Oncologic (may have fever also)
- Carcinoid tumor
- Neoplasia, general
- Neuroblastoma
- Pheochromocytoma
- Neurologic
- Generalized
- Anxiety
- Fainting
- Gustatory or Olfactory
- Citric acid
- Coffee
- Chocolate
- Peanut butter
- Spicy foods
- Pain
- Shock
- Focal or regional
- Peripheral nerve damage
- Auriculotemporal syndrome (i.e. Frey’s Syndrome, nerve damage near parotid gland with focal sweating in area)
- Ross syndrome ( e.g. sweating associated with areflexia and tonic pupil)
- Spinal cord lesion
- Stroke
- Peripheral nerve damage
- Generalized
Questions for Further Discussion
1. How does iontophoresis work to decrease hyperhidrosis?
2. When should hyperhidrosis prompt an evaluation for a possible neoplasm?
Related Cases
- Disease
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Sweat
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:45-56.
Greenberg RA, Rittichier KK.
Pediatric nonenvironmental hypothermia presenting to the emergency department:
Episodic spontaneous hypothermia with hyperhidrosis. Pediatr Emerg Care. 2003 Feb;19(1):32-4.
Stolman LP.
Treatment of hyperhidrosis.
Dermatol Clin. 1998 Oct;16(4):863-9.
Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H, Ahn S, Stolman LP; Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis.
Recognition, diagnosis, and treatment of primary focal hyperhidrosis.
J Am Acad Dermatol. 2004 Aug;51(2):274-86.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Date
July 28, 2008
Pediatric Education 