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Research of primary hyperhidrosis in students of medicine of the State of Sergipe, Brazil* * Study performed at Universidade Federal de Sergipe and Universidade Tiradentes – Aracaju (SE), Brazil.

Abstract

BACKGROUND:

Hyperhidrosis or excessive sweat production occurs at 2.9-9% of the population.

OBJECTIVE:

To estimate the prevalence and disorders due to primary hyperhidrosis (HP) in medicine students in the state of Sergipe.

METHODS:

Cross-sectional study using individual interviews.

RESULTS:

Hyperhidrosis was found in 14.76% of subjects, the most affected regions were palmar, plantar and axillary, causing prejudice in daily activities. Family history occurred in 45% and 22.72% was diagnosed by a physician.

CONCLUSION:

The prevalence of hyperhidrosis in medicine students of Sergipe was high, with strong family and a small portion of diagnoses made by medical professionals.

Keywords:
Hyperhidrosis; Epidemiology; Sweat; Students, medical

INTRODUCTION

Hyperhidrosis is a disorder defined as excessive sweat production by the body beyond what is required by homeostasis.1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.It can be classified as primary (PH) or secondary hyperhidrosis (SH). HP has no known cause and is characterized by excessive sweating due to hyperactivity of the sympathetic nervous system that innervate the sweat glands. HP manifests focally in usually symmetrical anatomical regions such as armpits, palms, soles, face and other areas. When excessive transpiration has a known cause, it is classified as SH whose etiology may be due to a variety of factors such as infection, malignancy, drugs, anxiety and neurological and endocrine disorders.2Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6.Some studies show a familiar component in PH, suggesting autosomal dominant inheritance of variable penetration for this disorder.3Yamashita N, Tamada Y, Kawada M, Mizutani K, Watanabe D, Matsumoto Y. Analysis of family history of palmoplantar hyperhidrosis in Japan. J Dermatol. 2009;36:628-31.In addition, there is also a climate and emotional influence in patients with this condition.4Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.The affection has no association with gender, although it occurs in overweight and obese.1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.,4Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.,5Li X, Chen R, Tu YR, Lin M, Lai FC, Li YP, et al. Epidemiological survey of primary palmar hyperhidrosis in adolescents. Chin Med J (Engl). 2007;120:2215-7.Among the therapeutic options for HP, antiperspirants, iontophoresis, botulinum toxin injection or surgical treatment are used. The main representative of the surgery is endoscopic sympathectomy, considered the gold standard for the possibility of HP's permanent cure.6Wolosker N, de Campos JR, Kauffman P, de Oliveira LA, Munia MA, Jatene FB. Evaluation of quality of life over time among 453 patients with hyperhidrosis submitted to endoscopic thoracic sympathectomy. J Vasc Surg. 2012;55:154-6.,7Reis GMD, Guerra ACS, Ferreira JPA. Estudo de pacientes com hiperidrose, tratados com toxina botulínica: análise retrospectiva de 10 anos. Rev Bras Cir Plást. 2011;26:582-90.

Epidemiological studies have found a PH prevalence ranging from 2.9% to 9% in the populations studied; therefore, this disease is not a rare event.1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.,2Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6.,4Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.,5Li X, Chen R, Tu YR, Lin M, Lai FC, Li YP, et al. Epidemiological survey of primary palmar hyperhidrosis in adolescents. Chin Med J (Engl). 2007;120:2215-7.There is a negative impact on patient's life, causing limitations in occupational, educational, social, physical and leisure activities.1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.,7Reis GMD, Guerra ACS, Ferreira JPA. Estudo de pacientes com hiperidrose, tratados com toxina botulínica: análise retrospectiva de 10 anos. Rev Bras Cir Plást. 2011;26:582-90.The magnitude of the losses in quality of life is comparable to conditions such as severe psoriasis, kidney failure and end-stage rheumatoid arthritis.8Hoorens, I, Ongenae K. Primary focal hyperhidrosis: current treatment options and a step-by-step approach. J Eur Acad Dermatol Venereol. 2012;26:1-8.Moreover, patients with hyperhidrosis has a higher prevalence of anxiety than that described in the general population and in patients with other chronic diseases.9Bragança GM, Lima SO, Pinto Neto AF, Marques LM, Melo EV, Reis FP. Evaluation of anxiety and depression prevalence in patients with primary severe hyperhidrosis. An Bras Dermatol. 2014;89:230-5.Nevertheless, HP is still underdiagnosed by health professionals and few studies assess its prevalence.7Reis GMD, Guerra ACS, Ferreira JPA. Estudo de pacientes com hiperidrose, tratados com toxina botulínica: análise retrospectiva de 10 anos. Rev Bras Cir Plást. 2011;26:582-90.,1010 Vorkamp T, Foo FJ, Khan S, Schmitto JD, Wilson P. Hyperhidrosis: evolving concepts and a comprehensive review Surgeon. 2010;8:287-92.In Northeast, Southeast and Midwest of Brazil, there are no studies that contemplate this disease.

The aim of this study is to estimate the prevalence and consequent disorders due to PH in medicine students in the State of Sergipe, located in Northeastern region of Brazil, as well as assess the most affected anatomical regions, the presence of family history and the percentage of HP diagnosis given by a physician.

METHODS

This is a cross-sectional study. Population considered for the sample size calculation of the research was medicine students from the Universidade Federal de Sergipe (UFS, campus and University Hospital) and Universidade Tiradentes (UNIT), both in the State of Sergipe. For the assignment of the total of students, it was requested to Academic Directories of these institutions the number of students enrolled in all periods of the related course in the second semester of 2011, resulting in 760 individuals. Of this total, 107 students were from UNIT (a private institution) and 653 from UFS (a public institution). Based on a previous study by Strutton et al1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8., which estimated a population prevalence of PH of 2.9%, a probability sample was calculated, considering an error of 5% and an accuracy of 1%, resulting in a sample of 447 students. Participants were randomly defined by statistical program BioEstat 5.0.

Collection procedures and data analysis

Data collection was made through individual interviews in private, air-conditioned environment with a questionnaire for students applied by academic staff, previously trained to complete the protocol. The questionnaire was structured with closed and open questions, addressing issues such as gender, date of birth, color, age of onset of symptoms, affected sites, diagnostic criteria and psychological, study, work and social disorders caused by PH, besides questioning if the patient consulted any health professional.1111 Haider A, Solish N. Focal hyperhidrosis: diagnosis and management. CMAJ. 2005 Jan 4;172(1):69-75.For the diagnosis, we considered the study by Haider et al1111 Haider A, Solish N. Focal hyperhidrosis: diagnosis and management. CMAJ. 2005 Jan 4;172(1):69-75., which defines as PH the positive answer to the first question and the presence of positive reaction to at least two questions (Chart 1). Medicine students who agreed to participate in the study were included in the research after signing the informed consent (IC).

Chart 1
Questionnaire

The study was performed in accordance with the recommendations of the Helsinki Declaration of 1989 and the Resolution 196/96 on research involving human subjects from the National Health Council and was approved by CONEP's ethics committee under the number 260511.

Collected data were entered into a spreadsheet using Microsoft Excel 2007. Results were analyzed using descriptive statistics of data through mean, absolute and relative frequencies. Analysis was inferential by chi-square test for categorical variables. We considered the significance level of 5% (p<0.05).

RESULTS

The study enrolled 447 medicine students of the State of Sergipe, 63 of them (14.09%) from UNIT and 384 (85.91%) from UFS. Of these, 225 (50.34%) were men and 222 (49.66%) were women, with age ranging from 18 to 52 years old (mean 23.04; SD=3.808). Participants were: 191 (42.74%) white; 232 (51.9%) brown; and 24 (5.36%) black.

Sixty-six participants declare to have HP, with a prevalence of 14.76% (66/447): 10 (15.15%) from UNIT and 56 (84.85%) from UFS. Of these, 39 (59.09%) were men and 27 (40.91%) were women, with no statistical difference between genders (p=0.123). The age of onset of PH were: 0 to 5 years (3.03%); 5 to 10 years (16.67%); 10 to 15 years (31.82%); 15 to 20 years (39, 40%); 20 to 25 (7.58%); and over 26 years (1.5%). Anatomical regions affected by PH were: palmar (39.62%); plantar (25.47%); axillary (22.65%); facial (9.43%); and cranial (2.83%). Diagnosis was made by a physician in 15 patients (22.72%). Familial relation with PH was reported by 30 (45%) participants (Table 1). Regarding skin color declared by the interviewees, the disease affected 24 whites (36.37%); 41 browns (62.21%); and one black (1.42%), not finding significant differences referring to PH (p=0.109).

Table 1
Variables studied in HP

In 47 (71.21%) of patients with the disease, the episode of excessive sweating occurs at least once during the week; in 50 (75.76%), excessive sweating is bilateral; 52 (78.79%) states that the aggravation of the condition is related to stress (Table 1). Of the participants, 25 (37.9%) claimed some sort of impairment in daily activities, whether in mental, study, work or social order (Graph 1).

Graph 1
Absolute Frequency of Compromised Activities of Daily Living triggered by PH

DISCUSSION

Strutton et al1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.conducted a study in the United States by sending letters with survey to 150,000 homes, which revealed a prevalence of PH in 2.9% of the study population, equivalent to 7.8 million people. The reported prevalence in 3 cities in southwest China, using a self-administered questionnaire with a sample of 33,000 people was 4.36%.5Li X, Chen R, Tu YR, Lin M, Lai FC, Li YP, et al. Epidemiological survey of primary palmar hyperhidrosis in adolescents. Chin Med J (Engl). 2007;120:2215-7.Augustin et al1212 Augustin M, Radtke MA, Herberger K, Kornek T, Heigel H, Schaefer I. Prevalence and Disease Burden of Hyperhidrosis in the Adult Population. Dermatology. 2013;227:10-3., in a study in Germany during individual dermatological examination with 14,336 adults, questioned about the occurrence of focal hyperhidrosis, finding a prevalence of 16.3%. A study performed by Fenili et al2Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6.in Brazil, using Haider et al1111 Haider A, Solish N. Focal hyperhidrosis: diagnosis and management. CMAJ. 2005 Jan 4;172(1):69-75.diagnostic criteria with individual interviews, found a prevalence of 9%. In this study, the frequency of PH found was 14.57%, which allows to emphasize the importance of this disorder in medicine students in the State of Sergipe. The prevalence of HP varied depending on the population studied and on the methodology applied. It is noteworthy that a higher prevalence was observed when the interviews were conducted presentially, individually and by specialized personnel.

In studies with general population, Park et al1313 Park EJ, Han KR, Choi H, Kim do W, Kim C. An epidemiological study of hyperhidrosis patients visiting the Ajou University Hospital Hyperhidrosis Center in Korea. J Korean Med Sci. 2010;25:772-5.found that the onset of symptoms occurred at mean age of 15 years. Fenili et al2Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6.showed that 55.55% of the population with PH noticed symptoms before 25 years old. This study gathered similar data, with 39.40% of the beginning of PH occurring between 15 and 20 years old. This is an important factor because this age group is marked by intense need to establish interpersonal relationships, to play sports and to perform work activities, and the development of these activities can be seriously affected by this disease.

Studies by Struton et al1Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.and Fenili et al2Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6.didn't show significant difference between genders in PH's involvement, what was also found among medicine students in the State of Sergipe. Lear et al, analyzing the US population, noted that PH affected 87.9% Caucasians, 8.4% African Americans, 1.7% Asians, 0.8% Hispanics, and 0.8% Indians.1414 Lear W, Kessler E, Solish N, Glaser DA. An epidemiological study of hyperhidrosis. Dermatol Surg. 2007;33:S69-75.This ethnic distribution was similar to that found in the present study, which showed whites and browns with greater frequency of PH among medicine students.

Park et al1313 Park EJ, Han KR, Choi H, Kim do W, Kim C. An epidemiological study of hyperhidrosis patients visiting the Ajou University Hospital Hyperhidrosis Center in Korea. J Korean Med Sci. 2010;25:772-5., Fenili et al2Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6., Lear et al1414 Lear W, Kessler E, Solish N, Glaser DA. An epidemiological study of hyperhidrosis. Dermatol Surg. 2007;33:S69-75.and Westphal et al4Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.verified, respectively, presence of positive family history in 34.1%, 43.7%, 44.44% and 50% of PH patients in their study. Other studies have suggested an autosomal dominant component of variable penetration for this disorder.3Yamashita N, Tamada Y, Kawada M, Mizutani K, Watanabe D, Matsumoto Y. Analysis of family history of palmoplantar hyperhidrosis in Japan. J Dermatol. 2009;36:628-31.This study identified the family influence in 45% of participants with PH, according to the literature previously cited.

Lear et al4Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.found that axillary region was the most affected by HP (73%) and exceeded palmar (45.9%) and plantar (41.1%) areas. Park et al1313 Park EJ, Han KR, Choi H, Kim do W, Kim C. An epidemiological study of hyperhidrosis patients visiting the Ajou University Hospital Hyperhidrosis Center in Korea. J Korean Med Sci. 2010;25:772-5., in turn, showed that palmar and plantar sites simultaneously were the most frequent, accounting for 32.2% of the sample. Westphal et al4Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.concluded that palmar PH was the most frequent form (36%), before plantar PH (21%) and axillary PH (18%). Among medicine students from Sergipe, palmar PH accounted for 39.62% of cases, followed by plantar (25.47%), axillary (22.65%), facial (9.43%) and cranial (2.83%) PH. In 75.76% of participants, excessive sweating was bilateral. This diversity may be due to the age of the population of this study: it is known that palmar and plantar PH begins earlier than axillary and facial PH.1414 Lear W, Kessler E, Solish N, Glaser DA. An epidemiological study of hyperhidrosis. Dermatol Surg. 2007;33:S69-75.

Medicine students have different motivations and expectations about the medical profession since the beginning of the course, which will be polished with difficulties, disappointments and rewards along the graduation.1515 Trindade LMDF, Vieira MJ. Curso de medicina: motivações e expectativas de estudantes iniciantes. Rev Bras Educ Med. 2009;33:542-54.These situations can trigger excessive sweating and cause embarrassment before their colleagues, professors, other health professionals and patients. In the present study, students mentioned psychological, study, work and social disorders due to this condition. PH, regardless of its sites, can difficult or even preclude these patients to perform some procedures, interfering with their career choice. Medicine students, for example, need in their practical activities greet by shaking hands, examine patients, handle tests, prescribe in the medical records, issue receipts, wear gloves, handle tools and computers, etc. These activities can become difficult because of the intense sweat on the palms, sometimes causing the patient to interpret it as nervousness of who is examining. In relation to axillary PH, people can interpret as carelessness or poor hygiene of the patient, especially when accompanied by bromohidrosis (foul odor). As for facial PH, dripping sweat may spill into the patient to be examined or even during surgery, contaminating the surgical field.

Although PH is not a rare disorder and it has very negative impacts on the life of patients, only 22.72% of medicine students in the State of Sergipe were diagnosed by a physician.1616 Stefaniak T, Cwigon M, Laski D. In the Search for the Treatment of Compensatory Sweating. ScientificWorldJournal. 2012;2012:134547.This fact is probably due to the small value or little knowledge of this impairment by health professionals.

CONCLUSION

Prevalence of PH in medicine students in the State of Sergipe is high. The most frequent age of onset of symptoms was 15 to 20 years, with no difference between genders or interference of skin color, but with strong family character. The most affected sites were palmar and plantar regions, followed by axillary region. PH was rarely diagnosed by a physician although, in this study, patients are medicine students, who participate in health care activities and report psychical, work, study and social impairment.

  • Financial Support: None.
  • How to cite this article: Lima SO, Aragão JFB, Machado Neto J, Almeida KBS, Menezes LMS, Santana VR. Research of primary hyperhidrosis in students of medicine of the state of Sergipe, Brazil An Bras Dermatol. 2015;90(5):661-5.
  • *
    Study performed at Universidade Federal de Sergipe and Universidade Tiradentes – Aracaju (SE), Brazil.

REFERENCES

  • 1
    Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperidrosis: results from a national survey. J Am Acad Dermatol. 2004;51:241-8.
  • 2
    Felini R, Demarchi AR, Fistarol ED, Matiello M, Delorenze LM. Prevalence of hyperhidrosis in the adult population of Blumenau-SC, Brazil. An Bras Dermatol. 2009;84:361-6.
  • 3
    Yamashita N, Tamada Y, Kawada M, Mizutani K, Watanabe D, Matsumoto Y. Analysis of family history of palmoplantar hyperhidrosis in Japan. J Dermatol. 2009;36:628-31.
  • 4
    Westphal FL, Carvalho MANC, Lima LC, Carvalho BCN, Padilla R, Karla K, et al. Prevalência de hiperidrose entre estudantes de medicina. Rev Col Bras Cir. 2011;38:392-7.
  • 5
    Li X, Chen R, Tu YR, Lin M, Lai FC, Li YP, et al. Epidemiological survey of primary palmar hyperhidrosis in adolescents. Chin Med J (Engl). 2007;120:2215-7.
  • 6
    Wolosker N, de Campos JR, Kauffman P, de Oliveira LA, Munia MA, Jatene FB. Evaluation of quality of life over time among 453 patients with hyperhidrosis submitted to endoscopic thoracic sympathectomy. J Vasc Surg. 2012;55:154-6.
  • 7
    Reis GMD, Guerra ACS, Ferreira JPA. Estudo de pacientes com hiperidrose, tratados com toxina botulínica: análise retrospectiva de 10 anos. Rev Bras Cir Plást. 2011;26:582-90.
  • 8
    Hoorens, I, Ongenae K. Primary focal hyperhidrosis: current treatment options and a step-by-step approach. J Eur Acad Dermatol Venereol. 2012;26:1-8.
  • 9
    Bragança GM, Lima SO, Pinto Neto AF, Marques LM, Melo EV, Reis FP. Evaluation of anxiety and depression prevalence in patients with primary severe hyperhidrosis. An Bras Dermatol. 2014;89:230-5.
  • 10
    Vorkamp T, Foo FJ, Khan S, Schmitto JD, Wilson P. Hyperhidrosis: evolving concepts and a comprehensive review Surgeon. 2010;8:287-92.
  • 11
    Haider A, Solish N. Focal hyperhidrosis: diagnosis and management. CMAJ. 2005 Jan 4;172(1):69-75.
  • 12
    Augustin M, Radtke MA, Herberger K, Kornek T, Heigel H, Schaefer I. Prevalence and Disease Burden of Hyperhidrosis in the Adult Population. Dermatology. 2013;227:10-3.
  • 13
    Park EJ, Han KR, Choi H, Kim do W, Kim C. An epidemiological study of hyperhidrosis patients visiting the Ajou University Hospital Hyperhidrosis Center in Korea. J Korean Med Sci. 2010;25:772-5.
  • 14
    Lear W, Kessler E, Solish N, Glaser DA. An epidemiological study of hyperhidrosis. Dermatol Surg. 2007;33:S69-75.
  • 15
    Trindade LMDF, Vieira MJ. Curso de medicina: motivações e expectativas de estudantes iniciantes. Rev Bras Educ Med. 2009;33:542-54.
  • 16
    Stefaniak T, Cwigon M, Laski D. In the Search for the Treatment of Compensatory Sweating. ScientificWorldJournal. 2012;2012:134547.

Publication Dates

  • Publication in this collection
    Sep-Oct 2015

History

  • Received
    20 July 2014
  • Accepted
    12 Nov 2014
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