Hyperhidrosis (overview) R61.9; G90.8

Localized or generalized, increased sweating with excessive increase in eccrine and/or apocrine secretion of sweat of varying aetiology.

• Primary hyperhidrosis (also known as primary focal hyperhidrosis) is described as an idiopathic, bilateral, largely symmetrical, non-physiological disorder (disease).
• Secondary hyperhidrosis occurs in the context of underlying diseases.

For studies, a resting sweat secretion of > 20 mg/palm/min. was defined for hyperhidrosis palmaris and > 50 mg/axilla/min. for hyperhidrosis axillaris.

A basic classification is made according to whether the hyperhidrosis is idiopathic (primary hyperhidrosis) or occurs in the context of underlying diseases (secondary hyperhidrosis). Primary hyperhidrosis is further subdivided according to its localization (e.g. axillary). Depending on the occurrence of excessive sweat secretion, a distinction is made between:

• Primary (idiopathic) hyperhidrosis without any recognizable underlying disease:
  • Hyperhidrosis axillaris
  • Hyperhidrosis pedum et manuum
  • Hyperhidrosis perinealis
  • Hyperhidrosis unilateralis
  • Hyperhidrosis universalis.
• Primary hyperhidrosis in combination with accompanying symptoms:
  • acrodynia
  • acrocyanosis
  • bromhidrosis
  • erythrophobia
  • Verrucae vulgares
  • Keratoma sulcatum
• Secondary hyperhidrosis as a consequence of other diseases:
  • Neuropathic disorders:
    • Plexus paralysis
    • Hemiplegia
    • Compensatory (e.g. with sympathectomy)
    • Carpal tunnel syndrome
    • Cervical rib.
  • Endocrinological disorders:
    • Hyperthyroidism
    • menopause
    • Pheochromocytoma
    • Adrenogenital syndrome.
  • Hyperhidrosis as paraneoplasia
  • Other underlying diseases:
    • 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, gustatory
  • Hyperhidrosis oleosa
  • Granulosis rubra nasi
  • Hamartoma, eccrine
  • Glomus tumor (focal hyperhidrosis)
  • Lacquer hand
  • Sweat gland nevus

Physiologically as a temperature regulator

Constitutional (idiopathic/primary hyperhidrosis): Primary focal hyperhidrosis occurs more frequently 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 more common in atopic patients

Reactive in infections

In endocrine disorders

In diseases of the central and peripheral nervous system (e.g. Horner's syndrome, auriculotemporal syndrome)

For various skin diseases (e.g. epidermolysis bullosa simplex, Weber-Cockayne, endangiitis obliterans, glomus tumors, Maffucci syndrome)

After sympathectomy

Iatrogenic triggering by taking medication (see below hyperhidrosis, drug-induced).

Thorough anamnesis; the main measure of hyperhidrosis is the restriction of activities of daily living, as it relates the degree of severity to the living environment.

The Minor sweating test is suitable for determining sweating areas of the body.

The Hyperhidrosis Severity Scale Test (HDSS) has proven to be useful as a simple measure for daily activities.

• Medical history: A thorough investigation of the causes is essential. Axillary hyperhidrosis is treated symptomatically, for which various options are available, which vary depending on the location of the hyperhidrosis (see Hyperhidrosis axillaris below).
• Procedure according to a controlled step-by-step plan:
  • Cleaning and skin care: Regular hygiene of the armpits.
  • This may include washing the armpits several times a day using deodorizing syndets or soaps (^Dermowas®, ^Sebamed®, etc.).
  • Shaving: remove underarm hair to inhibit bacterial growth (Corynebacterium tenuis) (see Trichobacteriosis axillaris)
  • Deodorants: Apply a deodorant several times a day to neutralize the unpleasant underarm odour. Powders have also proved effective.
  • Clothing: Wear loose-fitting, breathable shirts and undershirts (no synthetic fibers, cotton instead). No tight-fitting clothes.
  • Antihidrotics: Antiperspirants include locally applied chemical agents such as tanning agents, aldehydes and aluminum salts, which are used particularly for axillary hyperhidrosis. Common preparations include ^Odaban® Spray (20% aluminum chloride), Antihydral ^Ointment® (methenamine) and the new Axhidrox ^Cream® (glycopyrronium bromide).
    • Aluminum chloride: The duration of the effect varies depending on the individual reaction and frequency of application. The effect is not permanent, so regular applications are necessary (Griffo R et al. 2025).
    • Glycopyrronium bromide: Glycopyrronium bromide an anticholinergic is available both in cream (Axhidrox ^Creme®) and parenteral form (tablets/injections).
  • Iontophoresis: Used in particular for increased hand and foot perspiration, sometimes also for severe underarm perspiration. Ions are transported into the skin by means of a weak direct current of medication. The therapy can be carried out at home. The therapy is not suitable for pregnant women and patients with cardiac arrhythmia, pacemakers or endoprostheses. Initial: Therapy trial with 10 minutes/day (pulse current device) 4-5 times/week for 3-4 weeks. If proven effective, continue as home therapy with 3-4 treatments/week.
  • Hyperthermic local procedures: Newer physical methods such as radio frequency, microwave or ultrasound therapy are intended to destroy sweat glands in a targeted manner. They are mainly used for axillary hyperhidrosis (Stuart ME et al. 2020).

    Microneedle radiofrequency (FMR) is a relatively new method that is used to treat primary axillary hyperhidrosis. Here, deep thermal energy is applied to the apocrine sweat glands (Rummaneethorn P et al. 2020). The clinical effect is inferior to that of botulinum toxin (Rummaneethorn P et al. 2020).

  • Botulinum toxin: Treatment with botulinum toxin A represents a significant advance. It leads to an inhibition of the transmission of nerve stimuli to the sweat gland cells and is primarily used to treat axillary hyperhidrosis. The active ingredient is approved for the preparation Botox for this indication. The treatment is expensive; the effect is reliable. It is limited in time (6-11 months), but can be repeated if the effect diminishes. Dividing the hyperhidrotic areas into 2 × 2 cm skin patches has proven to be effective. For each field, 3 MU Botox (dilution: 100 MU Botox/5 ml 0.9% NaCl) are injected intradermally in a fan shape. The success of the therapy is checked after 2-3 weeks. Any 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 doctor!
• System therapy:
  • Anticholinergics (e.g. methanthelinium bromide (^Vagantin®) or bornaprine (^Sormodren®).
  • Naturopathic sage products (e.g. ^Sweatosan® N) are available for systemic use.
• Surgical treatments:
  • After all conservative methods have failed, various surgical methods can be considered depending on the localization (see below Hyperhidrosis axillaris). In the case of axillary hyperhidrosis, the 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 the case of hyperhidrosis pedum et manuum, as well as profuse whole-body sweating, endoscopic thransthoracic sympathectomy can be considered if other treatment options fail. The method is performed as a minimally invasive procedure via an endoscopic approach; it is effective and long-lasting. 2 major side effects have been described: postoperative pneumothorax < 2%; transient 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 chromosome 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. Griffo R et al. (2025) Sweating under control - when surgery can help. Derma aktuell 06: 8-10
5. Hamm H et al. (2005) Primary focal hyperhidrosis: disease characteristics and functional impairment. Dermatology 212: 343-353
6. 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
7. 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

8. Rummaneethorn P et al. (2020) A comparative study between intradermal botulinum toxin A and fractional microneedle radiofrequency (FMR) for the treatment of primary axillary hyperhidrosis. Lasers Med Sci 35:1179-1184.

9. 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
10. Stuart ME et al (2020) A systematic evidence-based review of treatments for primary hyperhidrosis. J Drug Assess 10: 35-50.