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CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 421-423  

Case report of psychosomatic illness: The management of primary hyperhidrosis with oral escitalopram


Department of Psychiatry, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Submission24-Aug-2020
Date of Decision31-Aug-2020
Date of Acceptance07-Sep-2020
Date of Web Publication16-Feb-2022

Correspondence Address:
Amey Y Angane
Department of Psychiatry, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_471_20

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  Abstract 


Hyperhidrosis is excessive, visible sweating without physical activity, which is not associated with physiological homeostatic response to maintain body temperature. The severity can be assessed by the Hyperhidrosis Disease Severity Scale. Hyperhidrosis causes severe psychological impairment, and left untreated may cause cutaneous infections. Topical 20% aluminum chloride is the first-line treatment for all cases of primary, focal hyperhidrosis irrespective of disease severity. Here, we report a case of primary hyperhidrosis with no response to topical aluminum chloride, iontophoresis, and oral anticholinergics who was not interested in invasive treatment modalities. On developing symptoms of anxiety, the patient was subsequently referred to the psychiatry department and successfully treated with clonidine and oral escitalopram. Primary hyperhidrosis did not recur even when clonidine was tapered off, and the patient was maintained on escitalopram. The use of selective serotonin reuptake inhibitors as a long-term maintenance agent for hyperhidrosis requires further study.

Keywords: Anxiety, escitalopram, palmar sweating, primary hyperhidrosis


How to cite this article:
Angane AY, Keshari PK, Unnithan VB. Case report of psychosomatic illness: The management of primary hyperhidrosis with oral escitalopram. Med J DY Patil Vidyapeeth 2022;15:421-3

How to cite this URL:
Angane AY, Keshari PK, Unnithan VB. Case report of psychosomatic illness: The management of primary hyperhidrosis with oral escitalopram. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 21];15:421-3. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/421/337804




  Introduction Top


Primary hyperhidrosis is excessive, visible sweating, which is not associated with homeostatic response to maintain body temperature. The isolated areas of palm, axilla, face, and soles or frequently a combination of palmoplantar and palmo-axillary areas may be involved. The prevalence of hyperhidrosis varies from 3% globally to 9% in tropical countries like India.[1],[2]

Hyperhidrosis is caused by sympathetic overactivity secondary to a complex interplay of bio-psycho-social risk factors including genetics and neuroticism. Social stigma and embarrassment due to symptoms cause severe psychological and social consequences. Untreated hyperhidrosis may lead to nail infections, warts, and heat rash. Therefore, treatment becomes necessary.[1],[3]

Treatment modalities encompass the use of local aluminum chloride hexahydrate, injectable botulinum toxin, iontophoresis, oral anticholinergics, and sympathectomy. There is a dearth of literature on the use of oral selective serotonin reuptake inhibitors (SSRIs).[1],[3],[4] In the following case report, we have explored the use of oral escitalopram in management.


  Case Report Top


A 19-year-old female presented to the psychiatry outpatient department of a tertiary care hospital with the chief complaints of restlessness, palpitation, and symmetric sweating over bilateral upper limb extremities and armpits since the past 5 years. Due to this, she would change her clothes 3–4 times a day. The patient felt embarrassed about her excessive sweating and had subsequently stopped going to school. Initially, the patient would have symptoms for 5–15 min, but over the past 3 years, the symptoms worsened. The patient had been treated by consultant dermatologists with topical 20% aluminum chloride, iontophoresis, and oral anticholinergics to no response. The patient was not interested in invasive treatment modalities. She began experiencing excessive anxiety over her symptoms since the past year and was subsequently referred. She described her anxiety as intrusive and uncontrollable, which was associated with restlessness, irritability, and poor concentration. She felt nervous, worried endlessly about her sweating, had trouble relaxing, and experienced the constant feeling of impending doom nearly every day for the past month. There was no similar family history and no history of any similar previous psychiatric episodes. At the time of presentation, the patient would experience excessive sweating throughout the day, and palmar sweat would drip on the floor. This was absent during sleep; however, no specific stressors could be elicited. No other area of her body was similarly affected. She had no other significant medical and medication history.

On general examination, the patient was found to be well nourished and thin built. Her weight was found to be 42 kg, blood pressure – 100/70 mmHg, and pulse rate – 88 beats/min. On examination, the patient's extremities were profusely sweating with sweat dripping down. The patient's extremities were cool to touch. Other examinations were unremarkable.

Baseline investigations including complete blood count, liver function tests, renal function test, thyroid function test, chest X-ray, and electrocardiogram were done, which were found to be within normal limits. Antidepressant-induced excessive sweating was ruled out as the patient had no prior history of consumption of SSRIs. As the symptoms of anxiety started 2 years after the patient presented with hyperhidrosis, the diagnosis of secondary hyperhidrosis was also ruled out. A diagnosis of primary hyperhidrosis and severe generalized anxiety disorder as per DSM-V criteria was made. The patient was found to have a score of 4 on the Hyperhidrosis Disease Severity Scale (HDSS) at baseline.[5]

The patient was started on tablet escitalopram 10 mg, tablet clonidine 100 μg BDS, and tablet clonazepam 0.25 mg TDS. After 14 days, the patient perceived mild improvement in restlessness and anxiety. However, profuse palmoplantar sweating continued to interfere with day-to-day activities. The dose of escitalopram was increased to 20 mg for better control of symptoms of restlessness and anxiety. The patient experienced severe giddiness, and thus clonidine was tapered off and stopped.

After 14 days, the patient perceived an overall improvement of 60% in her anxiety symptoms, but her HDSS score was still 4. Although there was an improvement in anxiety symptoms, the patient complained of excess sedation, and thus clonazepam was tapered and stopped. The patient was maintained on 20 mg escitalopram.

After 1 month, the patient experienced a 75% improvement in anxiety symptoms, and the HDSS score fell to 2. The patient was maintained on escitalopram for 3 more months, and the patient experienced a 90% improvement in anxiety symptoms with the HDSS score of 1.

Escitalopram was now gradually tapered off, and after 14 days, there was no recurrence of hyperhidrosis and anxiety symptoms. The improvement in the HDSS score was maintained. After 2 weeks, all medications were stopped completely. After 12 months of regular follow-up, there has been no evidence of relapse. The patient now has no symptoms of anxiety, and her HDSS score is 1.


  Discussion Top


Hyperhidrosis is considered a disorder of the sympathetic autonomic nervous system. In hyperhidrosis, the eccrine sweat glands present in the axilla, palm, sole, and craniofacial areas are hyperfunctional. They have sympathetic innervation. The postganglionic nerve fibers that synapse with eccrine sweat glands use acetylcholine as the neurotransmitter as opposed to other postganglionic sympathetic nerves that use norepinephrine as the neurotransmitter. Cortical projections to hypothalamus regulate sweating during heightened emotional states.[3] Hypothalamic sweat centers having regulatory control over eccrine sweat glands of the palm are more sensitive to emotional stimuli. Eccrine sweat glands in the axilla are involved in both thermoregulation and emotionally induced sweating.[6]

Hyperhidrosis may be primary or secondary. While the cause of primary hyperhidrosis is not yet well understood, secondary hyperhidrosis may occur due to alcohol and substance abuse, anxiety, endocrine disorders, respiratory and congestive heart failure, and malignancies. Although there is no physical examination and confirmatory testing to accurately diagnose primary hyperhidrosis, criteria for diagnosis include visible, excessive, and focal sweating for longer than 6 months without apparent cause and minimum two of the following: symmetric and bilateral sweating, occurrence at least once weekly, age <25 years at the onset, positive family history, sweating absent during sleep, and affecting the patient's daily activities.[4] The differential diagnosis includes pachydermoperiostosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome, Riley–Day syndrome, and glomus tumor. The HDSS is a single question validated survey that estimates the effect of sweating on daily activities and response to treatment. It has four grades of tolerability with a score of 1 being normal, 2 being considered mild hyperhidrosis, and 3–4 indicating severe hyperhidrosis.[5]

The first-line treatment for all primary focal hyperhidrosis is topical 20% aluminum chloride. Botulinum toxin injection, iontophoresis, and oral anticholinergics such as glycopyrrolate and clonidine may be considered for patients with poor response to aluminum chloride.[7]

There is a dearth of literature on the utility of oral SSRIs in hyperhidrosis. While SSRIs have been recorded to cause sweating, paroxetine has been successfully used in managing palmar-plantar hyperhidrosis.[8],[9] No data exist on the utility of other SSRIs in the management and maintenance of hyperhidrosis. SSRIs are the first-line treatment for generalized anxiety disorder. They are also used in major depressive disorder, obsessive–compulsive disorder, panic disorder, posttraumatic stress disorder, bipolar disorder, anorexia, and premenstrual dysphoric disorder. They primarily inhibit serotonin transporter in the brain, causing increased serotonin concentration in the synaptic cleft and improving the binding of serotonin to postsynaptic receptors. They also have a lower affinity for norepinephrine transporter and dopamine transporter, leading to adrenergic effects. Escitalopram, which is composed of pure active (S) enantiomers, is a benzofuran and with the fluorine halogen substituent on the aromatic ring responsible for its specificity.[10] As sympathetically innervated eccrine glands are hyperfunctional in primary hyperhidrosis, modulation of these central pathways may be responsible for decreased sweating in primary hyperhidrosis. However, the exact mechanism of action of SSRIs in the management of primary hyperhidrosis needs to be elucidated. Diarrhea, epigastric discomfort, and tremors are the major side effects that may limit its use.

Patients of hyperhidrosis thus need to be screened for coexisting psychiatric morbidities such as anxiety and referred to the psychiatry department for management. Consultant liaison between dermatologists and psychiatrists is also warranted in such cases to improve prognosis and treatment outcomes. This novel case report opens up a new avenue for research, exploring the use of escitalopram and SSRIs in general as a long-term maintenance agent for hyperhidrosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank Dr. Ajita Nayak, Professor and Head of Department, Department of Psychiatry, Seth GS Medical College and KEM Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Walling HW, Swick BL. Treatment options for hyperhidrosis. Am J Clin Dermatol 2011;12:285-95.  Back to cited text no. 1
    
2.
Muthusamy A, Gajendran R, Ponnan S, Thangavel D, Rangan V. A study on the impact of hyperhidrosis on the quality of life among college Students. J Clin Diagn Res 2016;10:CC08-10.  Back to cited text no. 2
    
3.
Lakraj AA, Moghimi N, Jabbari B. Hyperhidrosis: Anatomy, pathophysiology and treatment with emphasis on the role of botulinum toxins. Toxins (Basel) 2013;5:821-40.  Back to cited text no. 3
    
4.
McConaghy JR, Fosselman D. Hyperhidrosis: Management options. Am Fam Physician 2018;97:729-34.  Back to cited text no. 4
    
5.
Varella AY, Fukuda J, Teivelis MP, Campos JR, Kauffman P, Cucato GG, et al. Tradução e validação da hyperhidrosis disease severity scale. Rev Ass Méd Bras 2016;62:843-7.  Back to cited text no. 5
    
6.
Altman RS, Schwartz RA. Emotionally induced hyperhidrosis. Cutis 2002;69:336-8.  Back to cited text no. 6
    
7.
Primary Focal Palmar-International Hyperhidrosis Society Sweathelp.org; 2020. Available from: https://sweathelp.org/treatments-hcp/clinical-guidelines/primary-focal-hyperhidrosis/primary-focal-palmar.html. [Last accessed on 2020 Aug 03].  Back to cited text no. 7
    
8.
Beyer C, Cappetta K, Johnson JA, Bloch MH. Meta-analysis: Risk of hyperhidrosis with second-generation antidepressants. Depress Anxiety 2017;34:1134-46.  Back to cited text no. 8
    
9.
Praharaj SK, Arora M. Paroxetine useful for palmar-plantar hyperhidrosis. Ann Pharmacother 2006;40:1884-6.  Back to cited text no. 9
    
10.
Sanchez C, Reines EH, Montgomery SA. A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int Clin Psychopharmacol 2014;29:185-96.  Back to cited text no. 10
    




 

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