Hyperhidrosis Clinical Presentation

Updated: Jul 02, 2018
  • 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. [10]

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. [11]

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. [12] 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. [10] 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, [13] 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. [14]

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. [14]


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.



Hyperhidrosis may be idiopathic or secondary to other diseases, metabolic disorders, febrile illnesses, or medication use.

Generalized hyperhidrosis may be secondary to numerous conditions including the following:

  • Neurologic or neoplastic diseases

  • Spontaneous periodic hypothermia and hyperhidrosis: This is postulated to be a rare cerebral neurotransmitter disorder. [15, 16]

  • Metabolic disorders or processes (eg, thyrotoxicosis, diabetes mellitus, hypoglycemia, gout, pheochromocytoma, menopause)

  • Febrile illnesses

  • Medications: Use of medications may affect one or more components of human thermoregulation and induce hyperhidrosis. Agents such as propranolol, physostigmine, pilocarpine, tricyclic antidepressants, and serotonin reuptake inhibitors have been implicated. Efavirenz was recently described to induce excessive nocturnal sweating that resolved after dose reduction. [17]

  • Hodgkin disease or tuberculosis (in nocturnal hyperhidrosis)

Localized unilateral or segmental hyperhidrosis is rare and of unknown origin. The condition usually presents on the forearm or forehead in otherwise healthy individuals, without evidence of the typical triggering factors found in essential hyperhidrosis. Primary focal hyperhidrosis tends to arise on the palms, plantar feet, and axillae, as well as from the face and scalp of children and young adults; there seems to have a distinct subtype of craniofacial hyperhidrosis in postmenopausal women. [18]

Unilateral hyperhidrosis with accompanying contralateral anhidrosis is also rare. [19] Unilateral hyperhidrosis has been described on the right sides of the forehead, the nose, and the palmar surface of the right hand, with anhidrosis on the left hand.

Localized hyperhidrosis may also be associated with the following:

  • Gustatory stimuli (associated with Frey syndrome, encephalitis, syringomyelia, diabetic neuropathies, herpes zoster parotitis, and parotid abscess)

  • Eccrine nevus: This may be associated with severe localized hyperhidrosis. [20]

  • Eccrine angiomatous hamartoma: This is a rare, benign malformation characterized by both eccrine and vascular components. [21, 22] It is usually first evident at birth or during early infancy and childhood as a nodule or a plaque, usually solitary, involving acral skin. Although often asymptomatic, it may be associated with focal hyperhidrosis, hypertrichosis, and pain.

  • Peripheral neuropathy, organomegaly, endocrinopathy, monoclonal plasma-proliferative disorder, and skin changes (POEMS) syndrome

  • Burning feet syndrome