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 is a familial disorder. In 30-50% of cases other family members are affected. Little is known about the predisposing genes (see Hyperhidrosis palmaris et plantaris).
• Reactive in infections
• For endocrine disorders
• For diseases of the central and peripheral nervous system (e.g. Horner syndrome, auriculotemporal syndrome)
• For various skin diseases ( e.g. epidermolysis bullosa simplex, Weber-Cockayne, endangiitis obliterans, glomus tumours, Maffucci syndrome)
• after sympathectomy
• Iatrogenic triggering by drug intake (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 causes is essential. Axillary hyperhidrosis is treated symptomatically, for which there are various options available, depending on the location of the hyperhidrosis (see below hyperhidrosis axillaris).
• Procedure according to a controlled step 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 underarm hairs to inhibit bacterial growth (Corynebacterium tenuis) (see Trichobacteriosis axillaris)
  • Deodorants: Apply a deodorant several times a day to neutralize the unpleasant underarm odor. Powders have also proved effective.
  • Clothing: Wear breathable shirts and undershirts cut as wide as possible (no synthetic fibres, cotton instead). No tight-fitting clothes.
  • Antihidrotics: Antiperspirants include locally applied chemical agents such as tanning agents, aldehydes and aluminium salts, which are used particularly in cases of axilliary hyperhidrosis.
  • Iontophoresis: Used especially for increased hand and foot perspiration, sometimes also used for severe underarm wetness. The therapy is not suitable for pregnant women and patients with cardiac arrhythmia, pacemakers or endoprostheses. Initial: Therapy trial with 10 min/day (pulse current device) 4-5 times/week over 3-4 weeks. If proven effective, continuation as home therapy with 3-4 treatments/week.
  • Botulinum toxin: An essential progress is the treatment with botulinum toxin A. It leads to an inhibition of the transmission of nerve impulses to the cells of the sweat glands and is primarily used for the treatment of axilliary 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. The subdivision of the hyperhidrotic areas into 2 × 2 cm boxes has proven to be effective. Per box 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 monitored 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 doctor!
• systemic therapy:
  • For internal use there are various substances available such as sage products (e.g. Sweatosan N) or anticholinergics (e.g. methanthelinium bromide [Vagantin] or Bornaprin [Sormodren]).
• Surgical treatments:
  • After failure of all conservative methods, different surgical methods can be considered depending on the localization (see below Hyperhidrosis axillaris). For axillary hyperhidrosis, surgical 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 intervention via an endoscopic access; it is effective and permanently effective. 2 major side effects have been described: postoperative pneumothorax < 2%; passant compensatory sweating < 20%.

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