Dermato-Venereology Dept.

Medical Faculty
Hasanuddin University/
Dr. Wahidin Sudirohusodo Husodo

Introduction
Sweat glands
Structure : between 2-4 million sweat glands
across the human body.
Found in the dermis/lower part of the skin
Function : - Produce a watery secretion &
open on to the skin to help control
body temperature.
- Provide an emotional response to
stimulus.

Sweat glands
Two types : Eccrine sweat glands &

Apocrine sweat glands

Controlled by sympathetic nervous system
controls many of our involuntary actions
such as breathing, heartbeat and sweating.

ECCRINE

APOCRINE

Eccrine Sweat Glands

Wide distribution all across the body,

especially in the hands, feet & forehead.

Consist of ducts downward budding the

skin & secretory coils deep in the skin,

which create the sweat.

Eccrine Sweat Glands

Function :

- Thermoregulation - control the

temperature of the body.
- Emotional response - provide a
response to psychological stimulus

Eccrine Sweat Glands

Composition of the Sweat

- Watery clear, hypotonic (neutral)

solution
- Sweat consists of water & salts such
as sodium, chloride, potassium, urea,
bicarbonate, calcium & other excretions
from the body such as amino acids

Eccrine Sweat Glands

Nervous Control:

- These glands are under sympathetic

nervous control
- Activated to prepare the body for
physical activity or emergency
- Stimulated by acetylcholine (a
neurotransmitter)
- Respond to Botox therapy
- Also be controlled by neurosurgery

Eccrine Sweat Glands

Other regulating factors include:

Hormones,
Pyrogens (bacterial toxins),
Physical activities,
Emotional stimuli,
Temperature

Apocrine Sweat Glands

More limited distribution, but are found in the

following areas :
- Axilla (underarm),
- Perianal (near the anal area),
- Areolae, (nipple)
- Periumbilical (around the belly button),
- Genital area,
- External ear canal,
- Eyelids
- Also consists of ducts & secretory coils, but
these glands > larger than eccrine glands &
open onto hair follicles.

Apocrine Sweat Glands

Function:

- No known functions attributed to

apocrine sweat glands in humans.
- Genetic remnant of the mammalian
sexual scent gland

Apocrine Sweat Glands

Composition of apocrine sweat:

- Thick, milky fluid

- Excretions include protein, ammonia,
lipids, chromogranins (family of proteins)
- Bacterial decomposition leads to odor
- Produce proteins equivalent to
pheromones
in non-human mammalian species

Apocrine Sweat Glands

Nervous Control:

- Activated by same sympathetic nerves

as eccrine glands in the same region.
- Different nerve fibers & different nerve
transmitters control the glands
- Respond to catecholamine, not
acetylcholine
(unlike ecrine glands)
- Do not respond to Botox treatment

Characterized by sweating in excess of

the physiologic amount necessary

maintain thermal homeostasis.
Impairment :
- Activity daily living
- Social interactions
- Occupational activities

Absolute definition :

- > 20 mg of sweat per min per palm

Functional definition:
- Excessive sweating causing discomfort
for the person
- Vary from person to person

Sweating Nomenclature
Areas: Focal, regional, generalized
Symmetry: Symmetric or asymmetric
Classification: Primary vs. secondary
Type of sweating: Anhidrosis,

euhydrosis, hyperhidrosis

Hyperhidrosis

Etiology of generalized hyperhidrosis

Drugs, toxins, substance abuse
Cardiovascular disorders
Respiratory failure
Infections
Malignancies

-Hodgkins, myleoproliferative disorders,

cancers with increased catabolism

Etiology of generalized hyperhidrosis

Endocrine/metabolic disorders

-Thyrotoxicosis, pheochromocytoma,
acromegaly, carcinoid tumor,
hypoglycemia,
menopause
Neurologic
Rarely Idiopathic / Primary HH

Causes of Localized Hyperhidrosis

Usually Idiopathic / Primary
Social anxiety disorder
Eccrine nevus
Gustatory sweating
Freys syndrome
Impaired evaporation
Stump hyperhidrosis after amputation

Idiopathic (Primary) Focal

Hyperhidrosis
Onset mostly at puberty or early

adulthood
Predilection sites :axillae, palms, soles,
face
Pathogenesis : unknown

Etiology of Hyperhidrosis
Cortex: (Brain)
- Emotional response
- Mental
- Sensory
Hypothalamic Area (area of the brain
that
controls temperature, hunger & thirst)
- Exercise
- Thermoregulation
- Systemic diseases - infections, etc

Etiology of Hyperhidrosis
Medullary Area (area of the brain that
controls involuntary functions, like
breathing)
- Chiari malformations (malformation of
the brain) localized hyperhidrosis
- Infarction (stroke)

Etiology of Hyperhidrosis
Spinal Cord
- Syringomyelia (disease of the spinal
cord) also cause rare hyperhidrosis
- Spinal cord mass lesions (such as
tumors

Etiology of Hyperhidrosis
Axon reflex: (local nerve reflexes)
- Hyperhidrosis occur bordering
painful skin lesions such as venous
ulcers
Compensatory Mechanism:
- Post-sympathectomy (surgical
interruption of nerves)
- Ross syndrome

Etiology of Hyperhidrosis
Endocrine System: (Hormonal)
- Hyperthyroidism - excessive activity of
the thyroid
- Hyperpituitarism - excessive secretion
of the pituitary gland
- Increased release of catecholamine
(shock, fight-or flight response)

Etiology of Hyperhidrosis
Primary or Idiopathic Hyperhidrosis Cause unknown, usually appears in
localized areas:
- Axilla - underarms
- Palms of hand
- Soles of feet

Neural Hyperhidrosis :
Cortical Hyperhidrosis

Emotional Hyperhidrosis :
Excessive sweating occurs during
mental stress & may be associated
with takikardia & vasomotor
instability.

 The most responsive sweat gland in

cortical or emotional hyperhidrosis
those of the palms & soles, & the
axillae.
Localized emotional sweating
occasionally seen of the face,
especially over the upper lip &
forehead.

Hyperhidrosis of the Palms & Soles

( Volar Hyperhidrosis )
Definition : is excessive emotional
sweating of the palms & soles.

Epidemiology : all races & both sexes

commonly begins in infancy & childhood.

Etiology : genetic factor, probably

transmitted as an autosomal dominant trait.

Pathophysiology
Increased nerve tonus of the
sympathetic fibers supplying the
sweat glands
Increased nerve impluses from the
central nervous system with
excessive amounts of acetylcholine
& increased sweating responses.

Hyperhidrosiss patients of the palms

& soles electroencelphographic
(EEG) abnormalities; such as :
- Sharp wave bursts.
- Frontal cortexes are Hyperperfused.

Treatment
1. Tap water Iontophoresis the most
effective, safe & inexpensive.
Treatment of each palm (or sole) for 30
min at 15 - 25 mA anodal daily.

2. Local Treatment :
Formaldehyde, is temporally
effective & may induce contact
sensitivity.
Glutaraldehyde,less sensitizing.

3. Thoracis Sympathectomy
patients should be notified of the
potential side effects & possibility
of treatment failures.

4. Local injection of botulism toxin is a

new modality of treatment for palmar
hyperhydrosis.
5. Relaxation training & similar
psychotherapeutics techniques, may
be helpful.

Axillary Hyperhidrosis
Definition : excessive axillary
sweating rarely emit pungent axillary
odor.

Epidemiology : all races & both

sexes usually post-pubertal
(between 15 - 18 years).
Etiology : a genetically transmitted
individual.

Treatment
1. 25% Aluminium Chloride in alcohol
solution (Drysol) applied at bedtime, with or without subsequent
occlusion with a plastic film.

2. Severe hyperhidrosis, treatment

with Drysol is ineffective,
preliminary oral administration of
anti-cholinergic such as
Glycopyrrolate (1 mg) 45 min
earlier for the first to three nights of
treatment can be tried.

3. Thoracis symphatectomy (usually

second through fourth Thoracis
ganglia) the last resort.

Hypothalamic
Hyperhidrosis
As the major autonomic center within
the central nervous system
hypothalamus impulses that govern
thermoregulatory sweating essential
physiologic eccrine response.

The usual stimulus to the

hypothalamic elevation of the
temperature of the blood, although from
cutaneous sensory thermal receptors
also activate a response.

Pathophysiology
Chronic disease : Tuberculosis,
Malaria, Brucellosis & Lymphoma
induce thermogenic
hyperhidrosis physiologic
thermoregulatory sweating.

 Diabetic patients during severe

hypoglycemic episodes, those
which peripheral neuropathy
show a compensatory thermal
hyperhidrosis of the upper half of
the body anhidrosis of the lower
half.
Diabetics also show a gustatory
hyperhidrosis.

 Vasomotor Disorders a
sympathetic discharge
autonomic center for cutaneous
vasocontriction elicit sweating.
Tumors, Brain abscess,
Cerebrovaskuler accident
cortex contralateral
hyperhidrosis.

 Pheochromocytoma excitation
of higher autonomic center
catecholamine release
episodic sweating.

Medullary Hyperhydrosis
It is conveniently considered
under 2 clinical forms :
1. Physiologic medullary (gustatory)
hyperhidrosis.
2. Pathologic medullary (gustatory)
hyperhidrosis.

Physiology medullary hyperhydrosis

Symtomps
Localized sweating, usually of parts
of the face, after eating or drinking
sharp tasting or spicy foods &
beverages, especially the upper lip &
cheeks.

 Unusual forms, have been

described that involve other skin
areas, such as the scalp & even
the knee.
Etiology : Familial.

Pathophysiology
Concomitant vasodilatation occurs in
the sweating areas Reflex response
with an afferent arc deriving from taste
fibers of the glossopharyngeal nerve &
medullary nuclei as the reflex center
involve Symphatic fibers in cranial or
peripheral nerves affected skin area.

Treatment
No ideal therapy for physiologic
medullary (gustatory) hyperhydrosis.

Pathologic medullary hyperhydrosis

Three clinical forms of Pathologic
Medullary Hyperhidrosis :
1. Local trauma or disease of the
parotid gland.

2. Certain disorders of the central

nervous system, such as
sryingomyelia or encephalitis.
3. Injury to the thoracic sympathetic
trunk.

1. Local trauma or disesase of

Parotid Gland
Etiology :
Trauma.
Surgery.
Abscess.
Other disease of parotid gland

 Symptoms :
Unilateral localized pain.
Vasodilatasi.
Sweating in the distribution of
the auriculo-temporal nerve.

 Patophysiology
Response stimulation & vice versa
Chemical blockade of the otic
ganglion produces inhibition of
sweating & blockade of the
superior cervical ganglion prevent
to salivation.

2. Disorders of Central Nervous

System (Such as Syringomyelia
or Encephalitis)
Etiology :
Syringomyelia.
Encephalitis.
Symptoms : variable clinical
picture.

 Pathophysiology : lies within

the brain stem, where there is
disruption of the medullary
nuclei for sweating & salivation.

3. Injury to the thoracis sympathetic trunk

Etiology :
1. After sympathectomy,
2. Carcinoma of the Lung,
3. Osteoma of the Spine,
4. Subclavian aneurysma,
5. Thyroidectomi.

 Symptoms : the sweating responses

affect the face, neck, portions of the
trunk, upper extremities.

Patophysiology : Cholinergic fibers

from the Vagus nerve adjacent
preganglionic nerve of sympathetic
trunk.

Spinal sweating
Etiology :
Tabes Dorsalis.
Syringomyelia.
Symptoms : variable pattern of
segmental sweating.

 Patophysiology : the reflex

center lying in the intermediolateral cells of the cord.

Non neural sweating or

hyperhydrosis
Etiology :
Local Heat.
Drug, both cholinergic & adrenergic

The mechanisms is not clear, but it

may be related to the change in
blood flow through the affected skin
areas.

Compensatory hyperhydrosis
Etiology : Diabetes Mellitus,
Lesion in the spinal cord or
sympathetic trunk, & widespread
poral occlusion in atopic dermatitis
or in extensive miliaria.

Symptoms :
Facial Hyperhidrosis in patient
with generalized sweat retention
syndrome.
Distal anhidrosis due to Diabetics
Neuropathy.

Triggered by : thermal stimuli or

physical exercise.