Printer Friendly

Plantar hyperhidrosis.

Hyperhidrosis is a common condition in which a person sweats excessively. Excess perspiration may affect the whole body, or certain areas, including the feet, with both sides usually affected equally. Excess sweating is not a serious threat to health, but it can be embarrassing and distressing and have an adverse effect on quality of life. Hyperhidrosis is common. Almost 3% of the general population, largely people aged between 25 and 64 years, experience hyperhidrosis to some degree. (1) About 25% present to general medical practitioners and others to dermatologists and podiatrists. Wearing leather shoes and loose- fitting, cotton socks reduces the likelihood of the condition occurring and is mandatory in those affected. Early detection and management of hyperhidrosis can improve a patient's quality of life.

Hyperhidrosis can develop at any age, and is an important disorder in children and juveniles Primary hyperhidrosis typically starts during childhood, or soon after puberty, often in children between 6 and 16 years of age, (2) There is a dearth of good scientific papers on the management of plantar hyperhidrosis in the literature. (3) Long-term follow-up data are rare and some currently available treatment modalities are poorly understood. The podiatrist presented with recurrent fungal and bacterial foot and nail infections in a patient, should keep the diagnosis in mind and be prepared to treat the primary cause.

What is excessive sweating?

"Normal" sweating is not easily defined, but if the individual is spending a significant amount of time coping with sweating by frequent showering, foot-washing and sock-changing, they may have hyperhidrosis. Many people with the condition are too embarrassed to seek podiatric help, or believe that nothing can be done to improve it. It is usually a long-term condition, but some experience an improvement with time and treatments available can often keep the problem under control. In temperate climes wet feet encourage cold feet, a constant winter misery for sufferers. Wet, sodden feet encourage tinea pedis in toe clefts and the skin of the foot. The combination of sweat and dead skin cells can cause smelly feet, a source of social and psychological distress for the sufferer. If there is concurrent fungal or bacterial infection this can be a major consideration for the afflicted. The odour can permeate footwear to add to the embarrassment of sportsman/woman or adolescent using communal changing-rooms. This can be a source of unwanted attention and bullying in older children.

Causes of hyperhidrosis

Hyperhidrosis can be divided into two types, depending on whether an obvious cause can be identified. These are known as primary and secondary hyperhidrosis with plantar hyperhidrosis typically being primary and idiopathic.

Hyperhidrosis that has no obvious cause is known as primary hyperhidrosis and considered to be a defect in the sympathetic nervous system, with genes also playing a role. The sympathetic nervous system controls body functions that do not require conscious thought. It also acts like a thermostat controlling sweat gland activity. A specific type of sweat gland,-eccrine glands-appear to be involved in hyperhidrosis. There are more eccrine glands on, hands and feet than elsewhere, which may explain why these areas are often affected by hyperhidrosis. In cases of primary hyperhidrosis, the brain may send signals to the eccrine glands, even though there is no need to cool the body. Some cases of primary hyperhidrosis run in families, which suggests a genetic involvement. (3)

If a cause of hyperhidrosis can be identified, it is labelled secondary hyperhidrosis. This often starts more suddenly than primary hyperhidrosis and may affect the whole body. Triggers include:

* pregnancy and menopause

* anxiety states

* low blood sugar (hypoglycaemia)

* overactive thyroid gland (hyperthyroidism)

* obesity

* medications--including some antidepressants, propranolol, pilocarpine, and bethanechol

* infections, eg tuberculosis and HIV

* Parkinson's disease

* disorders of blood cells/bone marrow, eg Hodgkin lymphoma (cancer of white blood cells) (4)


Fungal infections

There is an overall increased risk of cutaneous infection in the presence of hyperhidrosis, including fungal, bacterial, and viral infections. (1) With a high risk of fungal infections development on the feet --most commonly fungal nail infections and tinea pedis. (4) Excessive sweat combined with wearing socks and shoes creates an ideal surrounding for fungi to grow. Fungal infections can be treated with antifungal creams. More severe cases may require antifungal tablets or capsules. (1)

Skin conditions

Excessive sweat can increase vulnerability to certain skin conditions, such as:

* warts--small, rough skin lumps caused by the HPV virus (human papillomavirus).

* boils--swollen red-yellow bumps that develop when a hair follicle becomes infected

Nail infections:

Patients with hyperhidrosis are more vulnerable to fungal toenail infections. The warm, moist environment offered by sweaty shoes is ideal for fungi to thrive.

Bacterial infections:

Patients with hyperhidrosis are more prone to developing bacterial skin infections, especially around hair follicles and between toes.

Body odour

Although people with hyperhidrosis sweat a lot, most do not have problems with body odour, as hyperhidrosis does not usually affect the apocrine sweat glands responsible for producing unpleasant-smelling sweat. However, if bacteria are allowed to break down the sweat, it can start to smell unpleasant. Eating spicy food and drinking alcohol can also make sweat secrete from eccrine glands. This can be prevented or eased by following lifestyle advice, such as frequently using antiperspirant spray

Managing hyperhidrosis

Hyperhidrosis can be challenging to treat. It may take a while to find the best treatment. Patients rarely seek a physicians help because many are unaware that they have a treatable medical disorder.. Doctors usually recommend starting with the least invasive treatment first, such as powerful antiperspirants.Lifestyle changes regarding hygiene, shoe-gear, insoles, and socks have to be encouraged such as:

* wearing loose and light socks

* avoiding triggers, such as alcohol and spicy foods, which could make sweating worse.

Some podiatrists recommend the wearing of sweat and odour-reducing shoe insoles. Made from latex and charcoal, they may ameliorate the problem and improve foot comfort.

Patient Advice.

* Use antiperspirant frequently, rather than deodorant.

* Avoid wearing tight, restrictive clothing and man-made fibres, such as nylon.

* Wear socks that absorb moisture, such as thick socks made of natural fibres, or special soles or sports socks designed to absorb moisture.

* Avoid wearing socks made out of manmade materials and change your socks at least twice a day if possible.

* Ideally wear shoes made of leather, and try to alternate between different pairs of shoes every day.

* The insertion of so called sweat-free or odour-reducing shoe insoles may be of benefit.

Treatment There are various topical, systemic, surgical and nonsurgical treatments available with varying efficacy rates. (5)


Antiperspirant containing aluminium chloride is often used to treat hyperhidrosis. This works by plugging the sweat glands. It should be applied at night just before sleep and washed off in the morning. The most common side effect of aluminium chloride is mild irritation or itching and tingling where it is applied. Using the antiperspirant less frequently can help reduce irritation. Using emollients (moisturisers) regularly and soap substitutes instead of soap may also help.


Anticholinergic or antimuscarinic drugs work by blocking the effects of a chemical called acetylcholine, which the nervous system uses to activate the sweat glands. Anticholinergics are available as tablets or solutions that are applied to affected areas. Propantheline bromide is an anticholinergic medicine licensed for treating hyperhidrosis. However, anticholinergic medicines unlicensed for hyperhidrosis--such as oxybutynin and glycopyrronium bromide--can also be prescribed if the doctor feels they might help .Possible side effects of anticholinergics include a dry mouth, blurred vision, stomach cramps, constipation and difficulty passing urine.


Iontophoresis may help excessive sweating that affects the feet. Iontophoresis involves treating affected areas of skin with a weak electric current passed through water, or a wet pad. This is thought to help block the sweat glands. Feet need to be placed in a bowl of water and a weak electric current is passed through the water. The treatment is not painful but the electric current can cause mild, short-lived discomfort and skin irritation. Each session of iontophoresis lasts between 20 and 30 minutes, and usually need two to four sessions a week for success. Symptoms should begin to improve after a week or two, after which further treatment will be required at one to four week intervals, depending on how severe symptoms are. (6)

Tap water iontophoresis is an effective method of treatment for primary palmoplantar and axillary hyperhidrosis in paediatric patients. There are still unanswered questions about the mechanism of action, ideal session intervals and protocols for maximum efficacy.. Patients may need regular visits to dermatology clinic to receive treatment. Alternatively, iontophoresis kits to be used at home may be recommended, with prices in the range of 250-500 [pounds sterling]. (7,8)

Botulinum toxin injections

Botulinum toxin can be injected into the skin in areas ofthe body affected by hyperhidrosis. This helps reduce sweating in these areas by blocking the signals from the brain to the sweat glands .Around 15-20 injections are given in the affected areas of the body, such as the armpits, hands, feet or face. The procedure usually takes about 30-45 minutes in total. The effect of the injections usually lasts for several months, after which time the treatment can be repeated if necessary. Potential side effects of botulinum toxin injections include:

* pain, redness or itching where the injections are given

* nausea, headaches and hot flushes after the injections are given

* another part of your body sweating more to make up for treated area--known as compensatory sweating

* muscle weakness around the treatment area

Most of these side effects are short-lived or will resolve as the effect of the injections wears off. Availability of botulinum toxin on the NHS can vary widely depending on local clinical commissioning group (CCG), and may only be available privately.


* Plantar Hyperhidrosis is common.

* Almost 3% of the general population are affected with hyperhydrosis

* Most affected are people aged between 25 and 64 years

* Podiatrist should keep the diagnosis in mind when dealing with recurrent fungal and bacterial infections

* The use of antifungal ointments and antibacterials may be necessary

* Patients should be advised to avoid man made fibre socks and shoes and use leather and cotton foot wear. Tight shoes and socks should be avoided

* Patients should use emollient foot washes and moisturisers rather than soap based product

* The Hyperhidrosis support group www. be helpful


(1.) Haider A1, Solish N Focal hyperhidrosis: diagnosis and management. CMAJ. 2005 Jan 4;172(1):69-75

(2.) Basedow S1, Kruse R, Bruch-Gerharz D Hyperhidrosis of childhood and adolescence: clinical aspects and

therapeutic options Hautarzt. 2011 Dec;62(12):928-34. doi: 10.1007/s00105-011-2225-7.

(3.) Singh S1, Kaur S1, Wilson P Plantar hyperhidrosis: A review of current management. J Dermatolog Treat. 2016 Apr 6:1-6.

(4.) Vlahovic TC Plantar Hyperhidrosis: An Overview Clin Podiatr Med Surg. 2016 Jul;33(3):441-51. doi: 10.1016/j. cpm.2016.02.010. Epub 2016 Mar 26.

(5.) Benson RA1, Palin R, Holt PJ, Loftus IM. Diagnosis and management of hyperhidrosis. BMJ. 2013 Nov 25;347:f6800. doi: 10.1136/bmj.f6800.

(6.) Dogruk Kacar S1, Ozuguz P, Eroglu S, Polat S, Karaca S Treatment of primary hyperhidrosis with tap water iontophoresis in paediatric patients: a retrospective analysis. Cutan Ocul Toxicol. 2014 Dec;33(4):313-6. doi: 10.3109/15569527.2013.875559. Epub 2014 Jan 9.

(7.) Ozcan D, Gulec AT.Compliance with tap water iontophoresis in patients with palmoplantar hyperhidrosis. J Cutan Med Surg. 2014 Mar-Apr;18(2):109-13.

(8.) Nagar R, Sengar SS. A Simple User-made Iontophoresis Device for Palmoplantar Hyperhidrosis.J Cutan Aesthet Surg. 2016 Jan-Mar;9(1):32-3. doi: 10.4103/0974-2077.178542. PMID:

Why Not Contribute to the Podiatry Review?

The Institute of Chiropodists and Podiatrists (IOCP) seeks to promote professional excellence and encourages creativity and innovation in practice. The IOCP aims to inform and educate its members and readership both nationally and internationally, with continuing professional development (CPD), whether student or practitioner. This is achieved through the publication of evidence-based practice, where the articles are clinically relevant and topical.

Podiatry Review, the IOCP's Professional Journal, endeavours to publish original articles on information supporting research, initiatives in clinical practice; such as case studies and government policies, literature reviews and education.

If you would like to contribute to the CPD of our members and readership we would welcome case studies, articles, Area Council and Branch news, plus appropriate photographs (with consent from all parties) or diagrams (suitably referenced to prevent copyright).

All case studies would need to be anonymised to protect your client/patients as per the Data Protection Act. Please see To submit your article, Area Council or Branch news or case study, or discuss ideas for an article or case study please email
COPYRIGHT 2016 Institute of Chiropodists and Podiatrists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2016 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:McIntosh, Iain B.
Publication:Podiatry Review
Article Type:Disease/Disorder overview
Date:Sep 1, 2016
Previous Article:Mobilisation of the tibio-talar and sub-talar joints.
Next Article:Podopaediatrics (tibial torsion).

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters