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Hyperhidrosis: Working Up a "Sweat"


Excessive sweating may be caused by a variety of conditions or prescription drugs.

How best to assess a male patient with paroxysms of "sweating"?

- Lincy Mathew, MD
   Fremont, Calif

Hyperhidrosis, or sweating beyond what is necessary to maintain thermal regulation, may be primary or secondary to a number of diseases and prescribed drugs. It may be localized (focal) or generalized. Regardless of the type or the cause of hyperhidrosis, it is often socially embarrassing and occupationally disabling. It has a profound effect on quality of life.

Primary essential or focal hyperhidrosis begins in childhood or even infancy and usually affects the hands, feet, and axillae. This physiologic disorder is frequently inherited and is made worse by heat and anxiety. Characteristically, it occurs during waking hours and recedes or disappears completely during sleep.

Various drugs, including β-blockers, physostigmine, pilocarpine, and tricyclic antidepressants, may cause generalized hyperhidrosis and sometimes focal hyperhidrosis. A number of neoplastic conditions, infectious disorders, and neurologic disorders and lesions can also cause generalized hyperhidrosis. Metabolic disorders such as thyrotoxicosis, hypoglycemia, menopause, and pheochromocytoma may account for the onset of hyperhidrosis in adults.

In assessing a patient with hyperhidrosis, the following questions are important:

  • What was the age at onset?

  • Is it generalized or localized?

  • Does the disorder occur around the clock or only while the patient is awake?

  • Did it follow drug exposure?

  • Is it associated with other symptoms that might point toward a neoplastic or infectious etiology?

  • Is there any accompanying neurologic deficit that might indicate a neurologic cause?

  • Are there associated physical findings, such as episodic hypertension, that might occur in a patient with pheochromocytoma?

For focal palmar and plantar hyperhidrosis, iontophoresis is highly effective and safe, and it remains the therapy of choice. Endoscopic sympathectomy carries with it a significant risk of compensatory hyperhidrosis and should rarely be recommended. Botulinum toxin A is a highly effective treatment for axillary hyperhidrosis. Certain drugs, including anticholinergics and clonidine, are sometimes useful for the management of generalized hyperhidrosis.

- Lewis P. Stolman, MD
   Associate Clinical Professor of Pediatrics and Dermatology
   New Jersey Medical School
   University of Medicine and Dentistry of New Jersey



  • Hornberger J, Grimes K, Naumann M, et al; Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004;51:274-286.

  • Stolman LP. Treatment of hyperhidrosis [published correction appears in J Drugs Dermatol. 2003;2:619]. J Drugs Dermatol. 2003;2:521-527.
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