Patterns Of Anhidrosis In Diabetic Neuropathy

There are a number of patterns of anhidrosis in diabetic neuropathy. A full appreciation of these patterns requires the administration of the thermoregulatory sweat test, a method that is not under widespread clinical use. Several well characterized patterns are described.

Distal Small Fiber Neuropathy

Perhaps, the most common pattern of anhidrosis is distal anhidrosis. The "burning feet" syndrome is perhaps the most common presentation of diabetic neuropathy. These patients have distal involvement with burning, prickling, and some stabbing discomfort with variable allodynia, and most have normal motor function. There is a subset of patients with completely normal motor function, intact tendon reflexes, and nerve conduction studies that are normal or near-normal. For this pattern of neuropathy, the underlying neuropathy has been assumed to be a length-dependent distal small fiber neuropathy demonstrable on skin biopsy (86). Autonomic fibers are presumed to be involved as well because these patients will usually have vasomotor symptoms, manifest as excessive coldness, discoloration, or sometimes erythromelalgia (53,87). Hyperand hypohidrosis can also be a feature. When sudomotor testing is used, approximately 80% of patients have abnormal QSART responses (53,88). There is good agreement between loss of intraepidermal fibers (somatic C fiber involvement) and QSART loss (autonomic C fiber involvement) (89).

Multifocal Sweating Loss

A common and characteristic pattern of anhidrosis in diabetic neuropathy is that of multifocal regions of sweat loss (10,28), which differs in distribution to other neuropathies (10). These patients have anhidrosis that affects parts of the body in the distribution of specific nerve trunks, plexus, or regions in the distribution of autonomic ganglia. The value of this test is that this pattern of loss reduces the number of likely causes. Apart from diabetes, this pattern is seen with autoimmune autonomic neuropathy and angiopathic neuropathy (although regional anhidrosis is usually not seen in this group of neuropathies).

Generalized Anhidrosis

An unusual pattern of anhidrosis is that of generalized anhidrosis, where there is total or subtotal anhidrosis (>70%). This pattern is seen in diabetic neuropathy, autoimmune autonomic neuropathy, chronic idiopathic anhidrosis, pure autonomic failure, and multiple system atrophy. In diabetes, percent anhidrosis provides one index of autonomic failure.

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Responses

  • fiori
    How common is anhidrosis?
    6 years ago

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