{'fraction_non_alphanumeric': 0.031746031746031744, 'fraction_numerical': 0.012145262145262145, 'mean_word_length': 4.84058988764045, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Epidemiologic analysis of prevalence of the hyperhidrosis*

Background The present paper aims to study the prevalence of the various manifestations of hyperhidrosis in patients who sought treatment in a specialized ambulatory in the state of São Paulo. Objectives Opposite to previous studies, this paper studies the different combinations of sweating sites, not being restricted to the main complaint site of the patients, but taking into consideration secondary complaints patients may present. Methods This was a retrospective approach of a database containing more than 1200 patients in which were mapped: combination of sweating sites, age of onset, age spectrum, mean age, body mass index and gender of patients. Patients were categorized into four groups based on their main sweating site - palmar, plantar, axillary and facial. Results We concluded that hyperhidrosis appears frequently in more than one site, being the main complaint that affects the most patients palmar hyperhidrosis, which appears early in the patients during adolescence. When there are two sites of sweating, the most frequent combination is palmar + plantar, and when there are three sites of sweating the most frequent combinations are palmar + plantar + axillary and axillary + palmar + plantar. Study limitations This research has casuistics limited to a single care service for patients with hyperhidrosis. Conclusion It is necessary to keep in mind that the disease manifests itself mainly in more than one location, with different intensities in each of the patients, generating a significant impairment of their quality of life.


INTRODUCTION
Hyperhidrosis (HH) is a disease characterized by excessive sweating -in addition to the physiologically necessary -which occurs mainly in the palms of the hands, armpits, soles and face, but can also affect the abdomen, chest, back, inguinal regions and lower limbs. 1,2 HH has an unknown etiology and is associated with intense emotional, occupational and social stress. It usually begins in childhood or adolescence and entails an important impairment in the quality of life of individuals who have it. 3 Studies from several parts of the world have been addressing the epidemiology of HH, but in most of them a limited portion of populations has been analyzed, thus their conclusions cannot be generalized. [4][5][6][7] In almost all of these studies, only the analysis of the site of major relevance of sweating is verified, not considering other possible associated sweating sites. Park et al.,  Within each group, two subgroups were analyzed more closely. The first, patients who had a single site of sweating in addition to the main one (total of two sites), and the second, patients who had two other sites of sweating in addition to the main one (total of three sites).
Associations between sweating sites most frequently found were listed in the tables.

Statistical analyzes Descriptive Analysis
Descriptive analyzes for the quantitative data were performed presenting medians (for age and BMI) and arithmetic means (for other data) accompanied by the respective percentiles. Qualitative variables were presented in frequency tables.

Inferential Analysis
Kruskal-Wallis test was used for the following variables: age and BMI. Chi-square test was used for the proportions of gender and onset phase.
A probability of error of type I (α) of 0.05 was considered in all inferential analyzes.
SPSS program, version 17, was used for statistical analysis.

RESULTS
The demographic data of patients are presented in table 1.
Analyzing the main complaints within each gender, we ob-served that, in both genders, the most prevalent complaints were palmar HH (48.0% in both genders) and axillary HH (36.2% in women and 36.6% in men), which appear in similar frequencies.
Analyzing genders within the main complaints, it is observed that, regardless of the main complaint, women have a higher prevalence of cases in relation to men.
We found that the majority of HH cases occur in individuals with a median age of less than 30 years, with the exception of facial HH, which appears in individuals with a mean age of 42 years.
Comparing medians of age among the four groups, there was no significant difference between the medians of age between the axillary and plantar main complaint groups (p = 0.49). The other groups presented significant difference (p = 0.001).
It is also observed the predominance of a normal BMI in patients with HH, with the exception of patients with facial HH who have a high BMI (29.0). In addition, all groups presented different mean BMI (p = 0.001), with the exception of the axillary and plantar groups, which presented a similar mean BMI (p = 0.43). We observed that patients whose main complaint was palmar or  Palmoplantar complaint was the most frequent (62.0%), followed by axillary-palmar (8.4%) and plantar-palmar (6.6%).
Of the 421 patients with three complaints, we found that 10 main combinations stood out, being present in 346 patients (82.0%).  There are two main treatments for HH. The first is thoracic sympathectomy, a low risk surgery with high success rate, but that generates compensatory HH in almost all patients to a greater or lesser degree. 1,13 The second one is drug therapy with oxybutynin hydrochloride, an antimuscarinic drug that has been shown to be a good treatment alternative for HH in all its manifestations. 14 Stud-   ies have shown that patients who receive oxybutynin as a form of treatment have improved quality of life both in the short and in the long term in all major sites (palmar, facial, plantar and axillary) and also in unusual places (such as back and inguinal regions). [15][16][17][18][19] Its main adverse event is dry mouth, an uncomfortable event that rarely leads the patient to abandon the treatment. Besides these two alternatives, it is also worth mentioning topical dermatological treatments and the use of botulinum toxin. 14 Similarly, in literature, we observed that more than twice as many women seek treatment in our outpatient clinic compared with men. This is explained by the greater aesthetic social pressure suffered by female patients, which leads them to seek specialized help sooner and more frequently. 20  Similarly to Park et al. 8 and Bragança et al., 9 we found that most patients had more than one HH site (85%). We observed that 68.1% of the patients analyzed had one to two HH sites, in addition to the site of main sweating.
In patients presenting three HH sites, there is a huge variety of possible combinations. In our study, we related the 10 most frequently encountered combinations, which in turn represent 82% of the total of these alterations, among them, the most common were palmar + plantar + axillary (55.5%) and axillary + palmar + plantar (25.4%).
This whole range of different forms of presentation of the disease demonstrates that when studying or treating HH, one should not only think of sweating site, as most of the studies published so far have done. It should be borne in mind that the disease manifests itself in more than one site, with different intensities in each of them and in all its presentations, generating a significant impairment of patients' quality of life.
In a patient with HH only in the hands, surgical treatment by sympathectomy with resection of the fourth thoracic ganglion is considered a great alternative; however, if the patient has palmar and facial HH, management should be resection of the second thoracic ganglion, which greatly increases the risk of severe compensatory hyperhidrosis. In cases where the patient has more than four sites of sweating, surgical treatment will probably also generate a greater chance of compensatory hyperhidrosis. Thus, it is important, for treatment selection, to assess the actual combination of patient sweating sites, rather than just the location of the primary complaint.

CONCLUSION
HH manifests itself more frequently in more than one site, and the main complaint that most affects the patients is the palmar, which appears already in the adolescence.
When there are two sweating sites, the most frequent combination is palmar + plantar, and when there are three sites of sweating, the most frequent combinations are: palmar + plantar + axillary and axillary + palmar + plantar. q