Hyperhidrosis (overview) R61.9; G90.8

Localized or generalized increased sweating with excessive increase of eccrine and apocrine secretion of sweat of different aetiology.

Primary hyperhidrosis (also primary focal hyperhidrosis) is described as an idiopathic, bilateral, largely symmetrical, non-physiological disorder (disease).

Secondary hyperhidrosis occurs in the context of underlying diseases.

Studies have defined a resting sweat secretion of > 20 mg/palm/min for palmar hyperhidrosis and > 50 mg/axilla/min for axillary hyperhidrosis.

A basic classification is made according to whether hyperhidrosis is idiopathic (primary hyperhidrosis) or occurs within the framework of underlying diseases (secondary hyperhidrosis). In primary hyperhidrosis, a further subdivision is made by localisation (e.g. axillary). Depending on the occurrence of excessive sweat secretion, a distinction is made between:

• Primary (focal) hyperhidrosis:
  • Hyperhidrosis axillaris
  • Hyperhidrosis pedum et manuum
  • perineal hyperhidrosis
  • unilateral hyperhidrosis
  • Hyperhidrosis universalis.
• Primary hyperhidrosis in combination with accompanying symptoms:
  • Acrodyny
  • Acrocyanosis
  • Bromhidrosis
  • Erythrophobia
  • verrucae vulgaris
  • Keratoma sulcatum
• Secondary hyperhidrosis:
  • Neuropathic disorders:
    • Plexus paralysis
    • Hemiplegia
    • Compensatory (e.g. for sympathectomy)
    • Carpal tunnel syndrome
    • Cervical rib.
  • Endocrinological disorders:
    • Hyperthyroidism
    • Climacteric
    • Pheochromocytoma
    • Adrenogenital syndrome.
  • Hyperhidrosis as paraneoplasia
  • Other:
    • Infectious diseases (tuberculosis, borreliosis)
    • Autoimmune diseases
    • Hypertension.
  • Rare syndromes with hyperhidrosis:
    • Acropathia ulcero-mutilans non-familiaris
    • Beri-Beri
    • Berlin Syndrome
    • Brünauer Syndrome
    • Burning feet syndrome
    • dyskeratosis congenita
    • Dysplasia, ectodermal
    • Diseases of the Epidermolysis bullosa simplex group
    • Fischer Syndrome
    • Auriculotemporal syndrome (Frey syndrome)
    • Page syndrome
    • Palmoplantar keratoses
    • Papillon-Lefèvre syndrome
    • phacomatosis pigmentokeratotica
    • Ross syndrome.
  • Exogenously induced hyperhidrosis:
    • Hyperhidrosis, drug-induced.
• Special forms:
  • Hyperhidrosis, drug-induced.
  • oleosa hyperhidrosis
  • Granulosis rubra nasi
  • Hamartom, eccrine
  • Glomus tumor (focal hyperhidrosis)
  • Lackhand
  • Sweat gland nevus

• Physiological in the sense of temperature regulation
• Constitutional (idiopathic); primary focal hyperhidrosis occurs in families. In 30-50% of cases, other family members are affected. Little is known about the predisposing genes (see Hyperhidrosis palmaris et plantaris).
• Hyperhidrosis palmaris et plantaris is frequent in atopics.
• Reactive in infections
• In endocrine disorders
• In diseases of the central and peripheral nervous system (e.g. Horner's syndrome, auriculotemporal syndrome)
• In various skin diseases (e.g. epidermolysis bullosa simplex, Weber-Cockayne, endangiitis obliterans, glomus tumors, Maffucci syndrome)
• after sympathectomy
• Iatrogenic triggering by medication (see below Hyperhidrosis, drug-induced).

A major factor in hyperhidrosis is the restriction of activities of daily living, as it relates the degree of severity to the living environment. The Minor sweat test is suitable for determining sweating body areas. The Hyperhidrosis Severity Scale Test (HDSS) has proven to be a useful simple measurement for daily activities.

• Anamnesis: A thorough investigation of the cause is indispensable. Axillary hyperhidrosis is treated symptomatically, for which various options are available, depending on the localization of the hyperhidrosis (see below Hyperhidrosis axillaris).
• Procedure according to a controlled stepwise plan:
  • Cleaning and skin care: Regular hygiene of the armpits.
  • This may include washing the armpits several times a day using deodorant syndets or soaps (Dermowas, Sebamed, etc.).
  • Shaving: remove armpit hair to inhibit bacterial growth (Corynebacterium tenuis) (see Trichobacteriosis axillaris).
  • Deodorants: Applying a deodorant several times a day to neutralize unpleasant underarm odor. Powders have also proved effective.
  • Clothing: Wearing loose-fitting, breathable shirts and undershirts as much as possible (no synthetic fibers, cotton instead). No tight-fitting clothes.
  • Antihidrotics: Antitranspirants include locally applied chemical agents such as tannins, aldehydes and aluminum salts, which are used especially for axillary hyperhidrosis. Common preparations are e.g. Odaban spray (20 % aluminum chloride), Antihydral ointment (methenamine) and new: Axhidrox cream (glycopyrronium bromide).
  • Iontophoresis: used especially for increased hand and foot sweating, sometimes also used for severe underarm weeping. The therapy is not suitable for pregnant women and patients with cardiac arrhythmias, pacemakers or endoprostheses. Initial: Therapy trial with 10 min./day (pulse current device) 4-5 times/week for 3-4 weeks. If effectiveness is proven, continuation as home therapy with 3-4 treatments/week.
  • Botulinum toxin: A significant advance is the treatment by botulinum toxin A. It leads to inhibition of transmission of nerve stimuli to the sweat gland cells and is primarily used for treatment of axillary hyperhidrosis. The active ingredient is approved for the preparation Botox for this indication. The treatment is expensive; the effect occurs reliably. It is limited in time (6-11 months), but can be repeated if the effect wears off. The subdivision of hyperhidrotic areas into 2 × 2 cm boxes has proved to be effective. 3 MU Botox (dilution: 100 MU Botox/5 ml 0.9% NaCl) is injected intradermally in a fan shape per box. The success of the therapy is checked after 2-3 weeks. Remaining hyperhidrotic areas can be re-injected if necessary. Side effect: Painfulness of the injections. Therapies with botulinum toxin belong in the hands of an experienced physician!
• Systemic therapy:
  • Anticholinergics (e.g. methanthelinium bromide [Vagantin] or bornaprine [Sormodren]).
  • Naturopathic sage products (e.g., Sweatosan N) are available for internal use.
• Surgical treatments:
  • After failure of all conservative methods, various surgical methods can be considered depending on the localization (see below Hyperhidrosis axillaris). In axillary hyperhidrosis, methods that can be used include sweat gland curettage, sweat gland suction curettage, and excision of the sweat gland areas with consecutive defect coverage.
  • In hyperhidrosis pedum et manuum, as well as in profuse whole-body sweating, endoscopic thransthoracic sympathectomy may be considered if other therapeutic options fail. The method is performed as a minimally invasive procedure through an endoscopic approach; it is effective and durable. 2 major side effects have been described: postoperative pneumothorax < 2%; passager compensatory sweating < 20%.

It is recommended to avoid situations and conditions that lead to excessive sweat production. It is important to aim for a normal body weight. Fundamental to this is a healthy and balanced diet. Hot "diaphoretic" spices, alcohol, hot coffee and tea, and nicotine should be reduced. In addition, it is recommended to wear breathable, airy and not excessively warm clothing (preferably made of natural fibers). It is also important to reduce and cope with stressful situations, which include well-planned schedules, relaxation exercises and appropriate endurance sports or compensatory leisure activities.

1. Chen J et al (2015) A novel locus for primary focal hyperhidrosis mapped on chromosomes 2q31.1 Br J Dermatol 172: 1150-1153
2. Finlay AY et al (1992) Dermatology life quality index (DLQI) - a simple practical measure for routine clinical use. Clin Exp Dermatol 19: 210-216

3. Fujimoto T et al (2013) Epidemiological study and considerations of primary focal hyperhidrosis in Japan: from questionnaire analysis. J Dermatol 40: 886-890

4. Hamm H et al (2005) Primary focal hyperhidrosis: disease characteristics and functional impairment. Dermatology 212: 343-353

5. Kuhajda I et al (2015) Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis. J ThoracDis 7 (Suppl 1): 5-11

6. Lowe NJ et al (2007) Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. J Am Acad Dermatol 56: 604-611
7. Strutton DR et al (2004) US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 51: 241-248