Station 48
Anita Bells
Age: 26 years old female
Full Case
Patient’s Data
Patient’s name: Anita Bells
Age- 26-year-old female
Past medical history
- Nil.
Drug and Allergy History
- Nil
Recent Notes/Consultations
- Nil
Patient booked a routine video consultation to talk discuss some concerns
Patient's Story (Role player’s brief)
You are Anita Bells, 26-year-old female.
Opening Line (if doctor asks, “How can I help?”): “I sweat excessively under both armpits. It’s been going on for about two years now, and it’s becoming really stressful for me.”
Additional Information (Volunteer only when asked appropriate questions):
The sweating is localised to your armpits only. It occurs almost every day, but stops completely at night while you sleep
You’ve tried various antiperspirants (e.g. Dove, Nivea roll-ons) but have not noticed any improvement. You’re not aware of their ingredients
You have no family history of similar issues. You have experienced no weight loss, no lumps, bumps or other concerning symptoms
Your mood is generally okay, but your self-confidence is being impacted
If Asked About Possible Triggers or Causes: You can’t identify any clear trigger, but you wonder if it’s related to coffee, since your symptoms seem to have become more noticeable and worsened during periods of increased coffee intake. You currently drink 3–5 cups of coffee daily
Social History: You do not smoke, do not drink alcohol, and do not use recreational drugs. You’ve been in a stable relationship with your partner of 5 years, and you live together. You work as a fashion model.
Ideas: You wonder if the sweating might be linked to caffeine use
Concerns: You work as a model, and the sweating causes visible patches on your clothing, which is embarrassing and affects your confidence, especially during jobs. However, you are not depressed or anxious.
Expectations: You’ve heard about a treatment called iontophoresis from a friend and would like to know if you can be referred for it. You’d also like the doctor to explain what it involves.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask how long the excessive sweating has been present
- Ask if the excessive sweating is limited to the armpits or also occurs in other areas of the body
- Ask whether the sweating is bilateral (if unilateral, consider secondary causes)
- Ask how often episodes of excessive sweating occur each week (primary hyperhidrosis typically occurs at least once per week)
- Ask if symptoms occur during sleep (primary hyperhidrosis does not usually cause night-time sweating — consider systemic disease or malignancy if present)
- Ask about potential triggers: stress, anxiety, caffeine, alcohol, spicy or hot food, sweets, chocolate, citrus, smoking, or exercise
- Screen for red flags or associated symptoms: fever, weight loss, anorexia, palpitations, or night sweats (to rule out systemic disease or malignancy)
- Ask how the sweating affects her daily life and confidenceand check for depression and anxiety
- Ask about occupation, stress levels, and social history including smoking, alcohol, and recreational drug use
- Ask about any family history of similar symptoms
- Give a diagnosis of Primary focal hyperhidrosis (axillary)
Example of explanation to patient
Thanks for explaining everything so clearly, Anita. Based on what you’ve described, particularly the fact that the sweating has been affecting only your armpits, is present most days, and doesn’t occur at night, this sounds very much like a condition hyperhidrosis which simply means excessive sweating.
This is a common condition, especially in younger people, and it happens when the nerves that control sweating become overactive. It’s not harmful, but as you’ve described, it can really affect confidence and quality of life, especially in your line of work.
You mentioned caffeine, and you’re right to wonder about a connection. Caffeine can sometimes act as a trigger by stimulating the nervous system, so reducing or avoiding it could help manage your symptoms.
You also mentioned iontophoresis, which is a valid and effective treatment, especially for localised sweating like in the underarms. Just to explain a bit more: iontophoresis is a specialist treatment. It involves passing a very mild electrical current through water, which temporarily blocks the nerves from sending signals to the sweat glands. For the underarms, there are special pads that connect to trays of water.
If you respond well to iontophoresis, you could see a significant short-term reduction in sweating, but it does usually require ongoing maintenance therapy to keep it under control. The equipment can be purchased for home use, but like I mentioned earlier, this treatment is specialist-initiated, which will require referral to a dermatologist
That said, there are some practical steps we can begin immediately, which might improve your symptoms and potentially avoid the need for specialist treatment.
- Try 20% aluminium chloride hexahydrate antiperspirants— these are available over-the-counter as roll-ons or sprays
- Apply it at night before bed, then wash it off in the morning
- Use it every 1–2 days as tolerated, until the symptoms improve
- Avoid known triggers like caffeine, as you’ve identified
- Wear loose-fitting clothing and avoid manmade fabrics which can trap sweat
- Choose white or black clothing (rather than colours like blue) to help mask visible sweat patches
- Consider using underarm pads to absorb sweat and protect your clothes
Since this is the first time, you’re seeking help for this and we want to be sure there’s nothing else going on, I’d also recommend some basic blood tests. These will help rule out any underlying medical causes such as:
- Thyroid function tests – to check for an overactive thyroid
- Full blood count – to look for signs of infection or anaemia
- ESR or CRP – to check for inflammation
- Urea and electrolytes – to assess kidney function
- Liver function tests
- HbA1c – to screen for diabetes
Finally, I want to acknowledge how this has been affecting your confidence, especially in a career where appearance matters. You’re absolutely right to seek help, and we’ll work together on a plan to manage this and get you feeling more confident again.
Management
Management
- Offer investigations including FBC, thyroid function tests, HbA1c, ESR/CRP, U&Es, and liver function tests to rule out secondary causes.
- Advise the patient to avoid identified triggers, particularly caffeine, as part of lifestyle and health promotion.
- If no obvious trigger is identified, advise the patient to keep a symptom diary to help identify any potential patterns or triggers over time.
- Recommend self-care strategies including frequent use of commercial antiperspirants rather than deodorants, avoiding tight clothing and manmade fabrics, wearing white or black clothing to reduce visible sweat patches, and using underarm pads to protect clothing.
- Advise on the use of 20% aluminium chloride hexahydrate topical preparations, explaining they should be applied to clean, dry skin at night before bed, washed off in the morning, and used every 1–2 days until symptoms improve, then as required (up to every 6 weeks), noting that skin irritation may occur.
- Address the patient’s ideas, concerns, and expectations by explaining iontophoresis, how it works, and when it is considered appropriate.
- Explain that iontophoresis is a treatment where a weak electrical current is passed through water to block nerve signals to sweat glands; for underarms, special pads are connected to water trays, and if effective, it can reduce sweating short term but requires regular maintenance and is usually initiated by a specialist, with machines available for home use.
- Offer conservative treatment and aluminium salt preparations as first-line before referring for iontophoresis.
- You can mention other second-line options such as botulinum toxin injections, which may be considered if conservative treatments fail.
- Offer follow-up to monitor response, provide ongoing support, and adjust the management plan as needed.
Learning point from this station:
Hyperhidrosis refers to sweating that exceeds the body’s normal requirements for thermoregulation. It can be classified by:Location or Cause
Location: focal (limited to specific areas) or generalised(affecting the whole body)
Cause: primary (idiopathic) or secondary (linked to an underlying condition)
Primary focal hyperhidrosis is the most common type. It typically affects the axillae, palms, soles, face, or groin and often starts in adolescence or early adulthood. It occurs without an identifiable medical cause, though up to 30–50% of patients report a family history, suggesting a genetic predisposition.
Secondary hyperhidrosis may be focal or generalised and is associated with underlying conditions such as anxiety, infections, malignancy, endocrine disorders (e.g. hyperthyroidism, diabetes), neurological conditions (e.g. Parkinson’s), or medication/substance use (including alcohol or opioids). It should be suspected in cases with generalised sweating, night sweats, or other systemic symptoms.
Key Principles of Management
- Baseline investigations should be arranged, especially at first presentation, if there are red flags, or if a secondary cause is suspected
- Advise patients to avoid identified triggers, such as caffeine, heat, stress, or spicy food
- Recommend self-care strategies, including lifestyle and clothing adjustments, and use of underarm pads
- Offer topical aluminium salt antiperspirants (e.g. 20% aluminium chloride), with guidance on correct use and how to manage potential skin irritation
- Provide information and support for managing associated psychological impact, such as anxiety or low confidence
- If symptoms persist after six weeks of self-care and topical treatment, or if these are not tolerated, refer to dermatology for specialist options such as iontophoresis, botulinum toxin injections, or systemic therapies