Prevalence of Primary Palmar Hyperhidrosis and its Impact on Hand Grip Strength and Quality of Life

Background: Primary palmar hyperhidrosis is a disorder resulting in abnormally excessive sweating of palmar side of hand. Patients present with cold and wet hands. It can also occur in combination with other areas like soles, axillae, and craniofacial region. Objective: To estimate prevalence of primary palmar hyperhidrosis in Faisalabad and its impact on hand grip strength and quality of life. Methods: This analytical cross-sectional study was conducted at Dermatology departments of three tertiary care hospitals of Faisalabad, Pakistan. Sample size was calculated using formula. Both genders with age ranging from 15 to 65 years were selected as participants using convenient sampling. Participants filled self-made form which included demographics, screening and valid and reliable quality of life measuring tools (HDSS and Keller scale). Then, after screening, grip strengths of hyperhidrotics (group 1) and non-hyperhidrotics (group 2) were measured using modified sphygmomanometer test (cuff method) and were compared. Data were analyzed using SPSS version 22. Results: Prevalence of primary palmar hyperhidrosis was 15.5% (11/71) consisting of 6 females and 5 males. Age of onset occurred during 5-15 years. 63.64% patients had positive family history. 90.91% patients had normal (18.5-24.9) BMI. Mean right and left grip strength values of hyperhidrotic patients were 168.55±55.446 and 157.55±44.568, respectively. Mean right and left grip strength values in non-hyperhidrotic participants were 157.63±53.126 and 148.67±53.85, respectively. 54.55% patients reported 3 on HDSS. On Keller scale majority reported mild to severe distress especially when shaking hands with others, writing papers, driving cars, grasping heavy objects, and wearing gloves. Conclusion: Current study showed 15.5% prevalence rate of primary palmar hyperhidrosis. Hand grip strength values of hyperhidrotic patients were higher when compared with non-hyperhidrotic participants. Majority of patients reported barely tolerable sweating which resulted in mild to severe distress experienced during activities of daily living.


Introduction
P rimary palmar hyperhidrosis is a disorder resulting in abnormally excessive sweating of palmar side of hand.Patients present with cold and wet hands.It can also occur in combination with other areas like soles, axillae, and craniofacial region.Diagnostic criteria include visible localized excessive sweating occurring without apparent cause.At least 2 of these characteristics should be present: bilateral and symmetrical sweating, onset occurring before 25 years, presence of family history, absence of sweating during sleep, and impairment 1 of daily activities.
Sweat centers in hypothalamus control sweating by activating sweat glands in skin and in case of hyperhidrosis hyperstimulation of normal sweat glands occur.Thermoregulatory sweating helps in heat dissipation from the whole body but is less evident on palms and 2 soles.On the other hand, emotional sweating also occurs all over the body but is most evident in palms and soles therefore helps in grip function.Emotional sweating is produced as physical sign in response to stimuli like stress, anxiety, fear, pain, focus, and attention.During grip function naturally small amount of sweat gets absor-

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bed in stratum corneum i.e., outer layer of skin.This moistens and softens skin's ridges/fingerprints providing larger contact area with the object than dry skin.Larger surface area helps in increasing net friction to allow good grip while a person is running or climbing in stressful condition or is attentively performing activities like writing, hand crafting, driving, eating, etc. Increased sweat in hyperhidrosis reduces friction making object handling difficult.Eccrine glands are found all over the skin but majority are found in palms and soles.Therefore, palmar hyperhidrosis in most cases occurs in 3 combination with plantar hyperhidrosis.Etiology of primary palmar hyperhidrosis is still understudy.But it can be classified as a genetic-hereditary trait, as a neurological dysfunction, as enzymatic or metabolic disorder, as an anatomical-histological change, or as a 4 pathophysiological condition.
Prevalence of palmar hyperhidrosis is 2.1% in Chinese adolescents whereas in other countries the range is 0.6% -5 10.4%.Diagnosis for palmar hyperhidrosis can also be made using questionnaire which eliminates the need of physical examination.This questionnaire is called Keller hyperhidrosis scale and has strong correlation 6 value of 0.723 when compared with peak sweat rates.Treatment options include topical antiperspirants, oral and topical anticholinergics, iontophoresis, botulinum toxin intradermal injection, surgical therapy, and high Skin friction is important for object handling but is affected by skin hydration, lubrication between contact surfaces, and material of object in contact.Friction increases for slightly moist skin but reduces for dry, greasy, wet or very wet skin.During grip-like contact slight sweat increases surface area of skin, provides thin layer of water between contacting surfaces for capillary adhesion, forms glue-like thin layer due to lipids and proteins in sweat.In case of hyperhidrosis skin is no longer moist, it becomes wet from moist to very wet reducing adhesion 10 and thus friction.Zackrisson et al. (2008) measured the effect of excessive sweating on grip force using force sensors installed in objects.They discussed that excessive sweating reduces friction between contacting surfaces of skin and object which results in slight slipping of object.It is overcome by exerting extra grip force (safety margin) to hold object in air.Reduced 11 sweating resulted decreased safety margin.Grip strength can also be measured using sphygmomanometer by performing some alterations in tool.This tool is easily accessible, valid and reliable having positive and Scarce literature was found about primary palmar hyperhidrosis and its impact on hand grip strength and quality of life in Pakistan.Therefore, rationale of this study was to estimate the prevalence of primary palmar hyperhidrosis and its impact on hand grip strength and quality of life.0.05) which is 1.96 and "d" is absolute error or precision which is 0.05 (5%)."p" is prevalence rate used in previous studies or pilot study.In previous study the prevalence rate of palmar hyperhidrosis was 0.6%-10%, therefore, for current study "p" was taken as 10% because 5 0.6% would have given very less sample size.Calculated sample size after putting values in formula was 71.

This cross-sectional study was conducted to estimate prevalence of primary palmar hyperhidrosis in
Using convenient sampling technique participates with or without primary palmar hyperhidrosis were selected presenting at outpatient dermatology departments of Faisal hospital, Allied hospital, and District Head Quarter hospital, Faisalabad, Pakistan.Participants for this study were taken with age ranging between 15 to 65 years 17 by taking into account a previous prevalence study.
Participants excluded from this study were those having any underlying medical condition, those who had undergone thoracic sympathectomy, and those who disagreed to participate.Consent was taken from those who wanted to participate in the study.All participants were asked to fill a self-made form which included demographics, screening for primary palmar hyperhidrosis, and quality of life measuring tools.Disease specific tools like Hyperhidrosis disease severity scale (HDSS) and Keller hyperhidrosis scale were used to measure quality of life of patients.HDSS is a 4-itemed scale and are scored from 1 to 4 according to severity of condition.Items are: 1) sweating is never noticeable and never interferers with daily activities, 2) sweating is tolerable but sometimes interferes with daily activities, 3) sweating is barely tolerable and frequently interferes with daily activities, 4) sweating is intolerable and always interferes with daily activities.HDSS has "r" value ranging from 0.35-0.77and Keller scale has Cronbach's α value of 0.89.18Participants were screened and diagnosed by the dermatologists and were divided into two groups (group 1 consisted of palmar hyperhidrotics and group 2 consisted of non-palmar hyperhidrotics) so that their grip strengths could be compared.
Grip strengths of participants of both groups were measured by researchers using modified sphygmomano-14 meter test (Cuff method).Cuff of sphygmomanometer was rolled into a cylindrical shape and was tied with tape.Then cuff was inflated till 20mmHg.After doing these alterations patient was asked to sit in chair with elbow resting on the table at 90 degrees and forearm in neutral position.Then the patient was asked to grip inflated cuff with maximum strength, hold it for 3-5s and then release it.Values were recorded bilaterally.20 was subtracted from each measurement and final values were recorded.Then quality of life of hyperhidrotic patients was assessed using HDSS and Keller scale which were included in form.
Data were analyzed using SPSS version 22. Grip strength values were described in the form of mean ± standard deviation.Prevalence, demographics, disease characteristics, HDSS and Keller scale scores were described in the form of frequencies.finding was similar to previous studies.Tools like dynamometers and specially designed force sensors were not used for grip strength measurement.Secondary palmar hyperhidrotic patients were not included for comparison.Another limitation of this study is that the prevalence rate was estimated in only one city therefore this rate can't be generalized to the whole country.For future research work on this topic, it is recommended to use dynamometers or force sensors for calculation of grip strength, also to include secondary hyperhidrotic patients and to estimate prevalence on national level.

Conclusion
In current study 15.5% prevalence was estimated for primary palmar hyperhidrosis which is relatively higher than previous studies.Hand grip strength values of hyperhidrotic patients were higher when compared with nonhyperhidrotic participants.Scores reported by patients on HDSS and Keller scale showed that hyperhidrosis has negatively impacted their quality of life.Majority of patients reported barely tolerable sweating which resulted in mild to severe distress experienced during activities of daily living.

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frequency ultrasound.Continuous sweating results in poor quality of life by affecting psychosocial, occupa-8 tional and personal domains of patient's life.According to recent case study palmar hyperhidrosis also results in fingerprint loss making use of fingerprint sensor and 9 touch screens difficult.

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correlation values ranging from 0.90 to 0.97.Different researches have compared sphygmomanometer with other tools like dynamometers and different force systems and have found moderate to good relationship between them.Souza et al. compared sphygmomanometer with dynamometer and found good correlation 14 between them.In a recent study O' Connor et al. compared sphygmomanometer with force frame system 15 and found good to moderate relationship.
Faisalabad City of Pakistan and its impact on hand grip strength April -June 2023 | Volume 29 | Issue 02 | Page 168 and quality of life.Approval was taken from ethical committee of Faisal Institute of Health sciences, Faisalabad, Pakistan.Sample size was calculated using the following formula which is used for sample size calcu-16 lation of cross-sectional studies : Sample size = Z is standard normal variate at 5% type 1 error (p< 1-α/2

Figure 1 :
Figure 1: STROBE diagram showing all stages of study.

Figure 2 .
Figure 2. Grip Strength values of both hyperhidrotic and non-hyperhidrotic participants

Table 2 :
Keller Hyperhidrosis Scale Scores

Table 1 :
Zackrisson et al. (2008)of Patients Figure 2 represents mean of bilateral grip strength values of both groups.Right and left grip strength values of palmar hyperhidrotic patients were 168.55±55.446and157.55±44.568,respectively.Right and left grip strength values of non-hyperhidrotic participants were 157.63±53.126and148.67±53.85,respectively.Tu et al. (2007) and Lai et al. (2015).In current study impact of palmar hyperhidrosis on grip strength was evaluated by using modified sphygmomanometer test.Bilateral mean hand grip strength values of hyperhidrotic patients were higher when compared with grip strength values of non-hyperhidrotic participants.Higher grip strength values in hyperhidrotic patients were because of applying extra force while griping cuff of sphygmomanometer.Zackrisson et al. (2008)showed similar results and discussed that hyperhidrotic patients have increased grip force because of Majority of patients reported a score ranging from 3 to 9 on Keller hyperhidrosis scale especially when shaking hands with others, writing papers, driving cars, grasping heavy objects, and wearing gloves.This by 25 HDSS.