Signs and Symptoms

Most cases of focal hyperhidrosis are idiopathic, with a possible genetic predisposition. Most commonly affected areas are the axillae, palms, and soles. There are no standardised diagnostic criteria for focal hyperhidrosis, and the diagnosis is based on history and physical signs.

History and Examination

• Relevant family history, H/O any co-morbidity, presence of risk factors.
• Sufferers do not sweat excessively during sleep. If sweating is present at night, then consideration should be made for further investigation as this would almost certainly be due to a secondary factor.

The use of the Hyperhidrosis Disease Severity Scale is accepted as a means of categorising the clinical severity of hyperhidrosis in primary care.

• Investigations are seldom, if at all, indicated for focal hyperhidrosis
• Generalised hyperhidrosis in a well patient with a classical history of sweating starting in late childhood and improving in middle age is seldom related to an underlying medical condition
• If the history is less typical e.g. symptoms starting in a different age group, night sweats or if the patient is unwell, there could be a secondary cause:
  • General medical conditions especially Parkinson's disease, diabetes mellitus or thyroid disease
  • Medications (new or recent withdrawal) - SSRIs, opiates, oestrogens and GnRH analogues can cause sweating. Sildenafil and apomorphine can cause craniofacial hyperhidrosis
  • Night sweats - could be due to lymphoma. Such a symptom warrants a thorough examination and CXR. If the patient has an associated fever investigate as per PUO (eg SBE, malaria, TB)
  • Rare conditions - if the attacks are associated with pallor, tremor or headaches consider a phaeochromocytoma or insulinoma. Ideally, the relevant investigations need to be done during an attack
• Flushing, as opposed to sweating
  • Flushing, as opposed to sweating, is likely to be associated with the menopause or rosacea
  • If patients are unwell during bouts of blushing, and have associated abdominal pain or diarrhoea, consider the carcinoid syndrome
• The Ross syndrome - extensive anhydrosis leads to islands of compensatory hyperhidrosis. Patients also have Aide's pupils (tonic pupils) and absent tendon reflexes

Formulary, Chapter 13. Skin: Management of hyperhidrosis

Primary focal hyperhidrosis

Initial management focuses on self-care management strategies and the use of topical aluminium salts.

Self-care management strategies include:

• Avoidance of any identified triggers where possible. 
• Using a commercial antiperspirant (as opposed to a deodorant).
• Moisture-wicking clothes/footwear that are loose fitting.
• Management of underlying or associated anxiety (N.B. drug treatments such as selective serotonin inhibitors may worsen symptoms).
• Some patients may wish to consider tap-water iontophoresis (particularly for palmar or plantar hyperhidrosis). These machines are not provided by the NHS in Devon but are available to rent or purchase. Advice is available from the British Association of Dermatologists (bad.org.uk) and Home - Hyperhidrosis UK.

Please note iontophoresis is no longer available in secondary care.

Aluminium Chloride preparations can cause irritation leading to discontinuation of treatment. This can be prevented in some cases by ensuring the skin is completely dry before application, and irritant dermatitis can be treated with a mildly potent topical steroid.

Consider treatment with an oral systemic anticholinergic where there is an inadequate response to at least 6 weeks of treatment with a topical aluminium antiperspirant and self-care management strategies. Where tolerated, topical aluminium products can be continued alongside oral treatment.

If response is inadequate after at least 6 weeks at the maximum tolerated dose of oxybutynin or propantheline, or treatment cannot be tolerated, consider making an Advice and Guidance request to Dermatology.

Botulinum toxin A is commissioned by NHS Devon for patients with severe axillary hyperhidrosis. Patients must have:

• a Hyperhidrosis Disease Severity Scale (HDSS) score of 3 or 4 despite at least six weeks of topical aluminium chloride and self-management strategies
• AND a resting sweat production of at least 100mg/5minutes (per axilla).

In severe cases which are unresponsive to these treatments, surgical intervention can be considered. However, the procedure (endoscopic thoracic sympathectomy) often leads to compensatory hyperhidrosis and so is rarely used in practice.

Please note iontophoresis is no longer available in secondary care.

Secondary hyperhidrosis

Initial management should focus on the identification and management of underlying causes. For patients with moderate to severe hyperhidrosis (HDSS score of 3 or 4) where symptoms persist despite the management of underlying causes, consider oral treatment with a systemic anticholinergic drug.

Where response is inadequate after at least 6 weeks at the maximum tolerated dose, or treatment cannot be tolerated, consider making an Advice and Guidance request to Dermatology.

Consider an Advice and Guidance request to Dermatology for patients with focal or secondary hyperhidrosis who:

• have failed to respond to 6 weeks treatment with oral anticholinergics at the maximum tolerated dose.
• are unable to tolerate treatment with oral anticholinergics

Focal hyperhidrosis

Consider Dermatology referral for patients with severe focal hyperhidrosis who have failed to respond to self-care and at least 6 weeks topical aluminium chloride.

Referral Criteria:

•  Hyperhidrosis Disease Severity Scale score of 3 or more (sweating which is barely tolerable and frequently interferes with daily activities)
• which has failed to respond to at least six weeks of topical aluminium chloride and self-management strategies.

Botulinum toxin A is only commissioned for use in patients with severe axillary hyperhidrosis. Patients must satisfy the above referral criteria AND have a resting sweat production of at least 100mg/5 minutes (per axilla).

In severe cases which are unresponsive to these treatments, surgical intervention can be considered. However, the procedure (endoscopic thoracic sympathectomy) often leads to compensatory hyperhidrosis and so is rarely used in practice.

Please note iontophoresis is no longer available in secondary care.

Generalised hyperhidrosis

Consider referral to Dermatology for patients with generalised hyperhidrosis where:

• underlying causes cannot be identified despite appropriate investigations.
• Symptoms persist despite management of underlying conditions and/or adjustments to potential causative medications

NHS Devon commissioning policy for Botulinum Toxin A for the management of focal hyperhidrosis

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of NHS Devon upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Exceptional /Individual Funding Requests (IFR).

Patient Information

MyHealth patient information - Hyperhidrosis

Evidence

South and West Devon formulary - Skin

The Primary Care Dermatology Society.

Pathway Group

This guideline has been signed off on behalf of NHS Devon

Publication date: 30 January 2017

Updated: 16 November 2023 (In line with the NHS Devon Commissioning policy)