Hyperhidrosis (excessive sweating): an overview of causes, symptoms and all the latest treatment options

Excessive, uncontrollable sweating – medically known as hyperhidrosis – is often far more than just a cosmetic nuisance for those affected. It can lead to significant psychological distress, impair social life and drastically reduce quality of life. Many people with hyperhidrosis feel self-conscious in everyday life, avoid certain situations or suffer from the visible consequences, such as soaked clothing (sweat patches) and the constant worry about body odour. This excessive sweating often occurs without any apparent cause, such as heat, exercise or other physical exertion.

As a specialist in surgery, with a particular focus on aesthetic and plastic surgery, I regularly encounter patients for whom excessive sweating causes significant distress and who are seeking effective solutions. Fortunately, there are now a wide range of treatment options available that can be tailored to the individual to alleviate excessive sweating. This article aims to provide you with a comprehensive and accessible overview of the causes, types, diagnostic procedures and, above all, the various treatment options for hyperhidrosis, based on the latest medical evidence.

Definition: What exactly is hyperhidrosis?

Hyperhidrosis is a condition characterised by excessive sweat production by the eccrine sweat glands, which goes beyond what is necessary to regulate body temperature; literally, it means „excessive sweating“. It is a functional disorder of the eccrine sweat glands, in which more sweat is produced than is necessary to cool the body. This excessive sweating often occurs regardless of the ambient temperature or physical exertion and cannot be controlled at will. In hyperhidrosis, on the other hand, sweat production is pathologically increased.

Types of hyperhidrosis: primary vs. secondary, focal vs. generalised

Doctors distinguish between various forms of hyperhidrosis:

Primary (idiopathic or essential) hyperhidrosis

• It usually occurs without any apparent underlying condition.
• It often begins as early as childhood or adolescence.
• Typically focal (localised) to specific areas of the body.

Secondary hyperhidrosis

• Occurs as a symptom of another underlying condition or as a side effect of taking certain medicines.
• Often generalised (affecting the whole body).

A distinction is also made based on the location of the sweating:

Focal hyperhidrosis

Affects only certain parts of the body. The most common are:

• Axillary hyperhidrosis: Excessive sweating under the armpits.
• Palmar hyperhidrosis: Sweaty hands (sweaty palms) affects the palms of the hands.
• Plantar hyperhidrosis: Sweaty feet – this affects the soles of the feet.
• Craniofacial hyperhidrosis: Excessive sweating on the face and head.
• Less commonly, the torso or groin.

Generalised hyperhidrosis

Excessive sweating all over the body. It may also affect only one half of the body or face.

Causes: Why do some people sweat excessively?

Symptoms and effects: More than just damp skin

The main symptom of hyperhidrosis is visible, uncontrollable and excessive sweating that is out of proportion to the ambient temperature or physical exertion. This can lead to sweat patches, clammy hands (sweaty hands) and feet, and can significantly impair the daily lives of those affected. The constant dampness can contribute to skin problems such as maceration, eczema or fungal infections. Furthermore, many people with hyperhidrosis suffer from considerable psychological distress and social limitations. The psychological burden is often very high.

Diagnosis of hyperhidrosis: How is it diagnosed and how is its severity assessed?

The diagnosis of hyperhidrosis is initially based on a careful review of the patient’s medical history and a physical examination.

Medical history and physical examination

The doctor will ask detailed questions to determine the nature, location and severity of the excessive sweating.

Specific tests (e.g. Minor iodine-starch test, gravimetry)

Various tests can be used to assess the severity and to pinpoint the exact location of the affected areas:

Iodine-starch test

The skin is coated with an iodine solution and then dusted with starch powder. Areas where the patient sweats heavily turn dark blue to black. This helps to visualise the exact extent of the sweating areas.

Gravimetry

A filter paper is placed on the affected area of skin for a specific period of time and weighed before and after use. The increase in weight corresponds to the amount of sweat excreted. This helps to objectively measure the severity of hyperhidrosis.

In addition, blood tests or other tests may be necessary to rule out secondary hyperhidrosis.

Treatment of hyperhidrosis: an overview of the options

Fortunately, there is now a wide range of treatment options available for hyperhidrosis. The choice of treatment depends on the type and severity of hyperhidrosis, the areas of the body affected (e.g. underarms, palms, soles of the feet), the patient’s level of distress, as well as individual factors and preferences. The aim is to reduce sweating and improve the quality of life for those affected.

Conservative and Topical Treatments

Antiperspirants (aluminium chloride preparations)

This is often the first line of treatment, particularly for axillary hyperhidrosis. Antiperspirants contain aluminium salts, which temporarily constrict or block the excretory ducts of the sweat glands.

Herbal remedies and home remedies (with a critical perspective)

Sage or relaxation techniques are sometimes mentioned. Their effectiveness in treating overt hyperhidrosis is generally not sufficiently proven scientifically, but they may have a supportive effect in individual cases.

Tap water iontophoresis

A tried-and-tested method, particularly for palmar (sweaty hands) and plantar hyperhidrosis. This involves immersing the affected parts of the body in water baths through which a weak direct current is passed.

Systemic drug therapy (tablets taken orally)

If topical treatments or iontophoresis are not sufficiently effective, or in cases of generalised hyperhidrosis, medication in tablet form may be used.

Anticholinergics

These medicines inhibit the action of the neurotransmitter acetylcholine, which also stimulates the sweat glands. They can reduce sweating throughout the body, but often cause systemic side effects (e.g. dry mouth). Their use must be monitored by a doctor.

Other medicines (beta-blockers, sedatives)

Less common and usually only used when stress or anxiety are identified as the main triggers for sweating.

Treatment with Botox (botulinum toxin injections)

Injections of botulinum toxin type A are a highly effective and recognised treatment for focal hyperhidrosis, particularly of the armpits, but also for the hands (hyperhidrosis of the hands) and feet. Botulinum toxin blocks the release of acetylcholine at the nerve endings that supply the sweat glands, thereby temporarily halting their activity. The effect usually lasts for several months.

Surgical and interventional procedures

If conservative and pharmacological treatments do not produce the desired results, more invasive procedures may be considered in cases of severe hyperhidrosis.

Sweat gland suction (suction curettage)

In this procedure, the sweat glands in the underarm area are permanently removed or damaged. This procedure is mainly used to treat axillary hyperhidrosis.

Sweat gland removal (excision)

The surgical removal of areas of skin containing sweat glands is now carried out less frequently.

Microwave thermolysis (e.g. miraDry®)

A non-invasive procedure that uses microwave energy to permanently destroy sweat glands in the armpits.

Laser therapy for sweat gland reduction

Various types of laser are being tested for the destruction of sweat glands.

Endoscopic Thoracic Sympathectomy (ETS) / Endoscopic Lumbar Sympathectomy (ELS) – with particular consideration of the risks involved

A surgical procedure in which parts of the sympathetic nervous system, which controls sweating, are severed. This is a last resort for very severe hyperhidrosis of the hands (palmar hyperhidrosis) or feet (plantar hyperhidrosis). A significant risk is compensatory sweating, whereby those affected begin to sweat more in other parts of the body.

Psychological aspects and support for those affected

The psychological distress caused by hyperhidrosis can be considerable. Psychological counselling or psychotherapy can help those affected to learn how to cope with the condition, boost their self-confidence and develop coping strategies. Often, psychological well-being improves simply as a result of successful treatment for hyperhidrosis.

Which doctor is the right person to speak to?

The first point of contact is often the GP. Specialists in hyperhidrosis are usually dermatologists (skin doctors), but may also be neurologists or endocrinologists, particularly if a secondary form of hyperhidrosis is suspected or if specific treatments such as taking certain medicines or botulinum toxin injections are required.

Frequently Asked Questions (FAQ) about hyperhidrosis