Letter to the Editor: January 2024

Reactive Hyperhidrosis Induced by Topical Products 

Dear Editor:

Hyperhidrosis (HH), a dermatologic condition characterized by sweat production beyond thermoregulatory needs, affects approximately five percent of the population in the United States.1 The etiology of HH is attributed to malfunctioning of the central autonomic nervous system, resulting in neurogenic overactivity of otherwise normal eccrine sweat glands.2  Here, we report the first case to our knowledge of HH triggered by topical products, including a moisturizing cream and an alcohol-based hand sanitizer.

A 41-year-old female with no known medical conditions presented to the clinic due to chronic profuse sweating of her face, palms, axillae, groin, and feet. She denied taking any medications and stated that her episodic, profuse sweating episodes were triggered mainly by topical products, including moisturizers and hand sanitizers, and, on occaison, emotional stress. However, she stated her condition was not triggered by other physical stimuli such as hot/cold temperatures, vibration, or pressure. At the time of the physical exam, the patient had mild dry skin throughout her body, including the affected areas, as she often hesitated applying moisturizers. During the first visit, she developed severe sweating of her palms immediately after applying a hand sanitizer containing 62% ethyl alcohol (Figure 1). Other ingredients included water, glycerin, propylene glycol, and carbomer. The patient was diagnosed with hyperhidrosis and was prescribed oral glycopyrrolate 1-2 mg every morning for symptom control.

At the patient’s one-month follow-up visit, she reported no significant improvement of HH with oral glycopyrrolate.  During the visit, stimuli of hot-cold temperature/water, pinprick-induced pain, vibration, and pressure, including stroking the skin, failed to elicit reactive HH on her palms. Nevertheless, application of a fragrance-free moisturizing cream containing hyaluronic acid and ceramides induced immediate palmar hyperhidrosis (Figure 2).  

HH can be classified as either primary or secondary forms. Primary HH is usually symmetrical and bilateral in nature and typically affects the palms, soles, axillae, face, and/or scalp. Secondary HH is usually associated with underlying medical conditions, such as diabetes mellitus, and/or certain medications, including antipsychotic agents, antidepressants, and opioids.3 

To the best of our knowledge, HH triggered by skin contact with topical products has not yet been reported. We propose a new clinical variant of HH triggered by skin contact with topical products, which we call “reactive hyperhidrosis.” We postulate that some of the chemical ingredients of certain topical products, including some moisturizers and alcohol-based hand sanitizers, can induce HH by stimulating cutaneous thermo-chemoreceptors, which in turn activate the sympathetic nervous system to release acetylcholine causing the eccrine glands to produce excessive sweat.2  

Our case report raises awareness for potential future research to advance understanding of the etiology and treatment of HH and suggests that the underlying pathophysiology of HH may also involve a dysregulation at the level of the primary sensory neurons in the skin, including hypersensitivity of pharmacologic receptors in the sweat glands and/or altered pharmacologic receptor function.

With regard,

Aislyn Oulee, MD; Roy Mendoza BS; and Ethan Nguyen, MD

Keywords. Emotional sweating, excessive sweating, hyperhidrosis, palmar sweating, primary hyperhidrosis, secondary hyperhidrosis, hyperhidrosis triggers

Affiliations. Dr. Oulee is with Riverside Community Hospital in Riverside, California. Mr. Mendoza is with the University of California Riverside School of Medicine in Riverside, California. Dr. Nguyen is with Raincross Dermatology in Riverside, California. 

Funding. No funding was provided for this article.

Disclosures. The authors report no conflicts of interest relevant to the content of this article.

References

  1. Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Etiology and clinical work-up. J Am Acad Dermatol. Sep 2019;81(3):657-666. doi:10.1016/j.jaad.2018.12.071
  2. Sato K, Kang WH, Saga K, Sato KT. Biology of sweat glands and their disorders. I. Normal sweat gland function. J Am Acad Dermatol. 1989/04/01/ 1989;20(4):537-563. doi:https://doi.org/10.1016/S0190-9622(89)70063-3
  3. Gorelick J, Friedman A. Diagnosis and Management of Primary Hyperhidrosis: Practical Guidance and Current Therapy Update. J Drugs Dermatol. Jul 1 2020;19(7):704-710. doi:10.36849/jdd.2020.5162.   
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