Hyperhidrosis – when excessive sweating becomes a medical problem

Sweating is a normal mechanism by which the body regulates its temperature. But when it happens to excess, unrelated to the ambient temperature or to physical effort, it can become a medical condition called hyperhidrosis.

Hyperhidrosis affects millions of people and can have a significant impact on social, professional and emotional life, according to studies by the International Hyperhidrosis Society. The good news is that there are modern, effective and minimally invasive treatments.

What is hyperhidrosis?

Hyperhidrosis is the production of an excessive amount of sweat, beyond the body's normal need. Sweating is normally a mechanism by which the body regulates its temperature. When it happens to excess, unrelated to the ambient temperature or to physical effort, it becomes a medical problem, according to the Mayo Clinic.

The condition usually begins in childhood or adolescence. Those affected may sweat even at rest, or in situations with no obvious stress. Although it can appear anywhere on the body, the most commonly affected areas are:

• the underarms;
• the palms;
• the soles;
• the face, forehead and scalp.

Excessive sweating often affects several regions at once.

Types of hyperhidrosis: primary and secondary

Hyperhidrosis can be of two kinds, according to its cause.

Primary (idiopathic) hyperhidrosis is the commonest form and has no identifiable medical cause. The sweat glands are normal, but they are excessively stimulated by the sympathetic nervous system. It is recognised by a few typical features:

• it begins in childhood or adolescence;
• it appears symmetrically (both palms, both underarms and so on);
• there is often a family history;
• episodes usually occur weekly;
• it does not occur during sleep.

Secondary hyperhidrosis is the consequence of another condition or of taking certain medicines, and may be generalised. Among the common causes are:

• neurological or neoplastic conditions;
• metabolic and endocrine disorders (thyrotoxicosis, diabetes, hypoglycaemia, gout, phaeochromocytoma, the menopause);
• febrile illnesses and infections (tuberculosis is classically associated with night sweats);
• Hodgkin's disease;
• chronic alcoholism.

Certain medicines can disturb the mechanisms of temperature regulation and induce hyperhidrosis, among them propranolol, physostigmine, pilocarpine, tricyclic antidepressants and serotonin reuptake inhibitors. In cases of secondary hyperhidrosis, the priority is to find and treat the underlying cause.

How common is excessive sweating, and how does it affect a patient's life

Although it is not a serious condition in itself, hyperhidrosis can significantly reduce quality of life. In the USA and the United Kingdom the estimated prevalence in the general population is about 1.6%, of whom roughly 60% are women, while in Japan the reported incidence is considerably higher.

Patients frequently describe:

• permanently damp clothes and visible marks on clothing;
• discomfort at shaking hands with others;
• difficulty handling paper or electronic devices;
• difficulty driving;
• an unpleasant smell associated with the sweat;
• anxiety and a loss of self-confidence.

Many patients come to avoid social or professional occasions because of this problem, which is why effective treatment has a major impact on quality of life.

How is the diagnosis made?

The diagnosis of hyperhidrosis is mainly clinical and is made by the dermatologist. During the consultation the following are assessed:

• the areas affected;
• the severity of the sweating;
• the impact on everyday activities;
• the existence of possible secondary causes.

Blood tests or other investigations may sometimes be recommended, to rule out an associated condition. To delimit the affected areas precisely, the Lugol's solution test (the starch-iodine test) can be carried out, which makes the areas of intense sweating visible.

Treating hyperhidrosis

Treatment is tailored to the severity and to the area affected, and can be challenging for doctor and patient alike. The options available today cover a wide range, from topical solutions to procedures in the clinic.

Medical antiperspirants and topical agents

Medical antiperspirants are the first treatment option. Topical agents include aluminium salts and topical anticholinergics.

Products with aluminium salts at concentrations of up to 20% have become the first line of treatment. They are applied in the evening to dry skin, and to limit irritation they are washed off the next day, with the skin neutralised if necessary with a bicarbonate solution. Other substances have been used over time (boric acid, tannic acid, resorcinol, potassium permanganate, formaldehyde, glutaraldehyde, methenamine), but these proved strongly sensitising, stained the skin and had a short-lived effect.

As for topical anticholinergics, the FDA has approved two products for primary hyperhidrosis in adults and children over the age of 9: sofpironium gel (Sofdra, approved in 2024) and glycopyrronium tosylate (Qbrexza, approved in 2018). Both are currently unavailable in Romania.

Systemic medication

Systemic medication includes anticholinergic agents such as oxybutynin. These are less appealing, though, because of their side effects: dilated pupils, blurred vision, dry mouth, dry eyes and constipation. In palmoplantar hyperhidrosis, beneficial effects have also been described for calcium channel blockers, indometacin and certain sedatives.

Iontophoresis

Introduced in 1952, iontophoresis consists of passing a low-intensity current through a bath of water, and can significantly reduce sweating after several sessions. Its limitations are the frequency needed (2 to 3 sessions a week) and the fact that it applies only to palmoplantar hyperhidrosis.

Treatment with botulinum toxin

Treatment with botulinum toxin is considered one of the most effective for underarm hyperhidrosis, and is also used with success for the palms, the soles and the forehead.

How does it work? Botulinum toxin temporarily blocks the release of acetylcholine, the substance responsible for stimulating the sweat glands. The result is a significant reduction in sweating over a period of about 6 months, sometimes longer, after which the procedure can be repeated.

How does the procedure go? The treatment is simple and consists of administering the botulinum toxin through 25 to 40 micro-injections for each underarm, palm or sole, and takes about 20 to 30 minutes. It is carried out in the clinic, needs no recovery period, and the patient can go straight back to their day. For the palms and soles the procedure is more painful, which is why a local anaesthetic is applied.

Surgical options

In severe cases, or those resistant to treatment, the following may be recommended:

• curettage of the underarm sweat glands;
• surgical treatment by sympathectomy, reserved for severe forms.

Is treatment with botulinum toxin safe?

Yes. When carried out by an experienced doctor, treatment with botulinum toxin for hyperhidrosis has a very good safety profile. The commonest reactions are minor and temporary:

• slight discomfort on injection;
• small bruises;
• passing local tenderness
• Transient muscle weakness (palms)

Frequently asked questions about treating hyperhidrosis

Will sweating appear elsewhere after the treatment?

As a rule, no. The body keeps its normal mechanisms of temperature regulation, and sweating is not “redirected” to other regions after local treatment with botulinum toxin.

Does the body need to sweat?

Yes. The treatment reduces sweating only in the area treated, without affecting the body's general ability to regulate its temperature.

Can I exercise after the treatment?

Yes. It is advisable, though, to avoid intense physical effort, the sauna and hot baths for the first 24 hours.

When is it time to see a dermatologist?

A consultation is advisable if the sweating:

• appears for no obvious reason;
• interferes with everyday activities;
• affects social or professional life;
• occurs at night as well;
• is accompanied by other symptoms such as weight loss, fever or palpitations.

Treating hyperhidrosis at Dermestetica

At Dermestetica we assess each patient in order to identify the cause of the excessive sweating, and we choose the most suitable treatment together. For most patients with underarm hyperhidrosis, treatment with botulinum toxin gives quick, effective and long-lasting results, helping them regain their comfort and their confidence in everyday life.

See the prices and book a consultation to find the solution that suits you.