Hyperhidrosis
Excessive sweating; focal hyperhidrosis; generalised hyperhidrosis; gustatory sweating (Frey syndrome)
Hyperhidrosis is excessive sweating beyond physiological needs, affecting approximately 2–3% of the UK population. UK practice categorises it into primary focal hyperhidrosis (axillary, palmoplantar, craniofacial, single-site, bilateral, onset before 25, family history, ceases during sleep) and secondary generalised hyperhidrosis (systemic disease, malignancy, drug-induced, menopause, infection, diabetes, hyperthyroidism). New-onset generalised hyperhidrosis in an adult warrants workup for underlying cause — including occult malignancy (lymphoma, phaeochromocytoma, carcinoid). Treatment is stepwise — topical aluminium chloride, iontophoresis, botulinum toxin, oral anticholinergics, surgical sympathectomy.
Classification
- Primary focal hyperhidrosis — focal visible excessive sweating for at least 6 months without an apparent secondary cause, plus at least two of:
- Bilateral / symmetric distribution.
- Onset before age 25.
- Family history of similar hyperhidrosis.
- Cessation during sleep.
- Impairs activities of daily living.
- Episodes ≥ 1 per week.
- Secondary generalised hyperhidrosis — wide spectrum:
- Endocrine — hyperthyroidism, phaeochromocytoma, carcinoid, acromegaly, menopause, diabetes.
- Drug — SSRIs, opioids, cholinergics, naltrexone.
- Infection — TB, malaria, brucellosis.
- Malignancy — lymphoma (B symptoms), pancreatic adenocarcinoma.
- Neurological — Parkinson, stroke, spinal cord injury.
- Frey syndrome (gustatory) — after parotidectomy / facial trauma.
Workup
- New-onset adult generalised hyperhidrosis — workup for systemic / neoplastic cause.
- History — onset, distribution, triggers, drugs, fevers, weight loss, palpitations, lymphadenopathy.
- Bloods — FBC, U&E, glucose, TFTs, ESR/CRP, calcium; HIV / TB screen if relevant; 24-h urinary metanephrines if phaeochromocytoma suspected.
- CT NCAP / imaging in adult with new generalised hyperhidrosis + B-symptoms.
- Primary focal hyperhidrosis with classical features — no investigation needed.
Management
- Topical aluminium chloride hexahydrate 20% — first-line for axillary; nightly application for 1 week, then maintenance.
- Glycopyrronium 1% cream / wipes — anticholinergic; useful for facial hyperhidrosis.
- Iontophoresis — for palmoplantar; tap-water iontophoresis machine.
- Botulinum toxin A injection — axillary (NICE-recommended); palmoplantar; craniofacial. 4–9 month duration.
- Oral anticholinergics — propantheline, oxybutynin, glycopyrrolate; systemic side effects limit use.
- Microwave thermolysis (miraDry) — for axillary; outpatient; durable.
- Endoscopic thoracic sympathectomy — for severe palmar hyperhidrosis refractory to other measures; significant risk of compensatory hyperhidrosis.
- Treat secondary cause where identified.
References
- Hornberger J et al. Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis. J Am Acad Dermatol; 2004.
- NICE Clinical Knowledge Summary. Hyperhidrosis. NICE CKS topic, accessed 18 May 2026.
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