Changes

September 2023 — reviewed. A literature search was conducted to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The management recommendations have been updated in line with the current literature.

Update

Goals

To support primary healthcare professionals to:

• Make an accurate assessment, and identify any underlying causes of, excessive sweating.
• Offer appropriate treatment in primary care.
• Arrange referral to secondary care if appropriate.
• Provide advice and information to people with excessive sweating.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is it?

• Hyperhidrosis describes sweating in excess of normal body temperature regulation.
• It can be classified by its location (focal or generalized) and by the presence of an underlying cause (primary or secondary).
  • Primary focal hyperhidrosis has no underlying cause, and is also known as primary idiopathic, primary localized, or focal hyperhidrosis. It most commonly affects the axillae, and may also involve the palms, soles of the feet, face, scalp, and groin.
  • Secondary focal hyperhidrosis involves specific areas of the body, but is caused by an underlying condition.
  • Generalized hyperhidrosis affects the entire skin surface area, and usually has an underlying cause.
  • Nocturnal hyperhidrosis is associated with sleep disorders such as sleep apnoea and restless legs syndrome.
• Bromhidrosis describes unpleasant body odour, which may be associated with hyperhidrosis.

[BMJ Best Practice, 2020; Brackenrich, 2022; PCDS, 2022; Idiaquez, 2023]

What causes it?

• Generalized hyperhidrosis is usually secondary to an underlying cause, whereas focal hyperhidrosis is usually idiopathic. Less commonly, focal hyperhidrosis may also be secondary to a specific cause.
• Primary focal hyperhidrosis
  • The exact cause of primary focal hyperhidrosis is unknown, but a positive family history is reported in 30–50% of cases, suggesting a genetic association.
  • It is thought that excessive sympathetic activity of the autonomic nervous system affects the eccrine sweat glands, and it may be associated with environmental and emotional triggers.
• Secondary generalized hyperhidrosis
  • Anxiety — see the CKS topic on Generalized anxiety disorder for more information.
  • Physiological — pregnancy or menopause. See the CKS topic on Menopause for more information.
  • Cardiovascular — such as heart failure or endocarditis. See the CKS topic on Heart failure - chronic for more information.
  • Infections — acute or chronic viral or bacterial infections such as tuberculosis, brucellosis, HIV, and malaria. See the CKS topics on Tuberculosis, HIV infection and AIDS, and Malaria for more information.
  • Malignancy — Hodgkin's disease, myeloproliferative disorders. See the CKS topic on Haematological cancers - recognition and referral for more information.
  • Endocrine or metabolic — hyperthyroidism, diabetes mellitus (especially hypoglycaemia episodes), diabetes insipidus, phaeochromocytoma, acromegaly, carcinoid syndrome, hyperpituitarism, obesity, and gout. See the CKS topics on Hyperthyroidism, Diabetes - type 1, Diabetes - type 2, Obesity, and Gout for more information.
  • Neurological — such as Parkinson's disease, epilepsy, hypothalamic lesions. See the CKS topics on Parkinson's disease and Epilepsy for more information.
  • Drugs — such as cholinesterase inhibitors; antidepressants (venlafaxine, duloxetine, selective serotonin reuptake inhibitors, tricyclic antidepressants, trazodone, and mirtazapine); pilocarpine; propranolol, ciprofloxacin, aciclovir, esomeprazole, and opioids.
  • Drug or alcohol misuse or withdrawal — such as cocaine and heroin. See the CKS topics on Alcohol - problem drinking and Opioid dependence for more information.
• Secondary focal hyperhidrosis (less common)
  • Neurological — such as stroke; peripheral neuropathy; diabetic autonomic neuropathy; and reflex sympathetic dystrophy. See the CKS topics on Stroke and TIA and Diabetes - type 2 for more information.
    • Diabetic neuropathy may also cause gustatory sweating (induced by salivation or chewing).
    • Spinal cord lesions and tumours may directly cause hyperhidrosis, or indirectly result in compensatory hyperhidrosis.
    • Reflex sympathetic dystrophy (complex regional pain syndrome) is a rare disorder of the sympathetic nervous system that is characterized by pain, swelling, and vasomotor dysfunction of an extremity.
  • Intrathoracic — malignancy such as mesothelioma; cervical rib. See the CKS topic on Lung and pleural cancers - recognition and referral for more information.
    • Intrathoracic lesions may cause unilateral hyperhidrosis of the face, neck, and thorax due to compression of the sympathetic chain ganglion.
  • Head and neck — gustatory sweating may be due to injury or surgery to the parotid gland (such as Frey's syndrome); invasion of the cervical sympathetic trunk by tumour; and Herpes zoster of the preauricular area. See the CKS topic on Shingles for more information.
  • Other — such as Raynaud's phenomenon; rheumatoid arthritis; and cold injury. See the CKS topics on Raynaud's phenomenon and Rheumatoid arthritis for more information.

[BMJ Best Practice, 2020; Brackenrich, 2022; PCDS, 2022]

How common is it?

The true prevalence of hyperhidrosis is not known, as it is often under-reported by patients and under-diagnosed by healthcare professionals.

• It is estimated that between 1-3% of the US population experience hyperhidrosis, 90% of these are primary and more than half affect the axilla [McConaghy, 2018].
• World prevalence is 1%, with a higher prevalence of axillary hyperhidrosis in white people; and palmar, generalised, or craniofacial in South-east Asian people [BMJ Best Practice, 2020].
• Japanese people have the highest prevalence [Brackenrich, 2022].
• Primary hyperhidrosis typically begins during childhood (primarily affecting the palmoplantar areas) or adolescence (typically affecting the axillae).
  • The peak age of onset of primary hyperhidrosis is 15–18 years of age [BMJ Best Practice, 2020].
  • Males and females are affected equally, but females are more likely to discuss it with a clinician [McConaghy, 2018].

What are the complications?

Possible complications of hyperhidrosis include:

• Reduced quality of life — difficulties handling objects such as holding a pen or staining paper, gripping tools, playing musical instruments, driving, and using electrical equipment; social embarrassment and relationship difficulties; impaired school performance; frequent showering and changing of clothes; and staining and damage to clothing and shoes.
• Anxiety and depression — see the CKS topics on Generalized anxiety disorder, Depression in children, and Depression for more information.
• Bromhidrosis — describes unpleasant body odour, which arises from the byproducts of bacteria that colonise sweaty areas.
• Skin maceration, intertrigo, and bacterial superinfection — see the CKS topic on Candida - skin for more information.
• Fungal skin infections of the body, groin, and feet — see the CKS topics on Fungal skin infection - body and groin and Fungal skin infection - foot for more information.
• Pitted keratolysis — a superficial and sometimes malodorous infection of the pressure-bearing areas of the soles of the feet, characterized by crateriform pitting, which may coalesce to form irregular erosions.

[Lenefsky, 2018; BMJ Best Practice, 2020; Henning, 2022; Parashar, 2023]

What is the prognosis?

• The course of axillary and craniofacial hyperhidrosis is unclear, but the severity often declines with increasing age and it is uncommon in the elderly, suggesting it may spontaneously improve over time [BMJ Best Practice, 2020].
• Palmar hyperhidrosis usually worsens at puberty and rarely improves over a person's lifetime [BMJ Best Practice, 2020].
• There is a lack of reliable treatments, and recurrences (after treatment) are common [Brackenrich, 2022].

How should I assess a person with excessive sweating?

Assess the person to help determine if hyperhidrosis is primary (idiopathic), or secondary to an underlying cause.

• Ask about:
  • The location, distribution, and symmetry of excessive sweating — focal (likely primary) or generalized (likely secondary).
  • The frequency and duration of sweating episodes.
  • The age at onset of symptoms.
  • Any identified triggers such as anxiety, stress, heat, exercise, smoking, alcohol, caffeine, chocolate, spicy or citrus food, hot food, or sweets.
  • Sweating during sleep — may be due to an infective cause such as tuberculosis, or malignancy such as Hodgkin's disease.
  • Associated symptoms — such as fever, weight loss, anorexia, or palpitations, which may suggest underlying systemic disease.
  • Any drug treatments that may cause sweating, and any alcohol, drug misuse, or withdrawal.
  • The severity of the symptoms, using the validated hyperhidrosis disease severity scale (HDSS):
    • One point for sweating that is not noticeable and does not affect daily activities.
    • Two points if sweating is tolerable but sometimes interferes with daily activities.
    • Three points if sweating is barely tolerable and frequently interferes with daily activities.
    • Four points if sweating is intolerable and always interferes with daily activities.
    • 1-2 points is regarded as mild-moderate, 3-4 points is moderate-severe.
  • The psychosocial impact of symptoms on quality of life and associated anxiety, which may exacerbate symptoms.
  • Any family history of excessive sweating or possible underlying cause(s).
  • Any known co-morbidity that may cause sweating.
• Examine the person to assess:
  • The location(s) and distribution of visible excessive sweating.
  • Body weight and body mass index (BMI). See the CKS topic on Obesity for more information.
  • For any complications.
  • For any other signs suggesting an underlying cause for secondary hyperhidrosis.
• Arrange investigations and/or specialist referral if a diagnosis of secondary hyperhidrosis is suspected due to an underlying cause, depending on clinical judgement.
  • If a person has non-specific symptoms and signs, consider the following baseline investigations in order to guide appropriate management:
    • Full blood count.
    • Erythrocyte sedimentation rate and/or C-reactive protein.
    • Urea and electrolytes.
    • Liver function tests.
    • HbA1c.
    • Thyroid function tests.
    • Tests for HIV or tuberculosis, if indicated — see the CKS topics on HIV infection and AIDS and Tuberculosis for more information.
    • Blood film for malarial parasites, if indicated — see the CKS topic on Malaria for more information.
    • 24-hour urine collection for catecholamines, metanephrines (to exclude phaeochromocytoma) and 5-hydroxyindoleacetic acid (to exclude carcinoid tumours).
    • Chest X-ray.
• If a diagnosis of primary focal hyperhidrosis is suspected with no underlying cause identified, and specific diagnostic criteria are met, no routine investigations are needed in primary care.

Scenario: Management

From age 12 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of hyperhidrosis.

Search dates

May 2018 - September 2023

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

• (MH "Hyperhidrosis+") 
• AB hyperhidrosis OR hyperhydrosis OR TI hyperhidrosis OR hyperhydrosis
• AB excessive sweating OR TI excessive sweating 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
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• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
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• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
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• Scoping of topic
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Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
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  • Current interventions
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  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

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Competing interests declared for this topic:

None.