Hyperhidrosis Clinical Presentation

Updated: Mar 23, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD  more...
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Essential hyperhidrosis is a dermatologic and neurologic disorder characterized by excessive sweating of the eccrine sweat glands. [21]

Patients note excessive sweating in affected areas, which ultimately prompts them to seek medical attention.

Palmoplantar hyperhidrosis (excessive sweating of the palms and soles) is observed in persons with chronic alcoholism. [22]

Localized hyperhidrosis, unlike generalized hyperhidrosis, usually begins in childhood or adolescence.

Hyperhidrosis beginning later in life should prompt a search for secondary causes such as systemic diseases, adverse effects of medication use, or metabolic disorders. Harlequin syndrome is characterized by unilateral hyperhidrosis and flushing, predominantly induced by heat or exercise. [23] The sympathetic deficits are usually limited to the face.

An echo-Doppler study found impaired left ventricular filling in patients with essential hyperhidrosis, which is associated with cardiac autonomic dysfunction because sympathetic fibers to eccrine glands of the palms of the hand arise from stellate and upper thoracic ganglia, which also innervate the heart. [21] This study indicated that hyperactivity of the sympathetic nervous system in patients with hyperhidrosis may alter cardiac function in the long term.

The temperament and character profile for patients with essential hyperhidrosis has stimulated interest, [24] but data suggest that hyperhidrosis is not related to social phobia or personality disorder.

Excessive sweating may be primary (idiopathic) or secondary to medication or disease. Secondary causes include endocrine diseases such as diabetes mellitus, hyperthyroidism, and hyperpituitarism. In one series, one third of cases were neurologic in origin, including peripheral nerve injury, Parkinson disease, reflex sympathetic dystrophy, spinal injury, and Arnold-Chiari malformation. Additional causes to consider include pheochromocytoma, respiratory disease, and psychiatric disease. Asymmetric hyperhidrosis may suggest neurologic disease. [25]

Diagnostic criteria favoring primary hyperhidrosis include excessive sweating of 6 months or more in duration, with 4 or more of the following: primarily involving eccrine-dense (axillae/palms/soles/craniofacial) sites; bilateral and symmetric; absent nocturnally; episodes at least weekly; onset at age 25 years or younger; positive family history; and impairment of daily activities. [25]


Physical Examination

Visible signs of hyperhidrosis are clearly evident. If direct visualization of the affected areas by hyperhidrosis is desired, the iodine starch test may be used. This test requires spraying of the affected area with a mixture of 0.5-1 g of iodine crystals and 500 g of soluble starch. Areas that produce sweat turn black.



Severe cases of hyperhidrosis may adversely affect the patient's quality of life by causing great emotional distress, social embarrassment, and work-related disability (due to palmoplantar hyperhidrosis). It may also be linked with depressive symptoms. [26]

Palmoplantar sweating may result in irritation of the affected skin, ultimately leading to chafing.

Axillary hyperhidrosis may be malodorous, causing social embarrassment.