Intended for healthcare professionals

Clinical Review

Diagnosis and management of hyperhidrosis

BMJ 2013; 347 doi: (Published 25 November 2013) Cite this as: BMJ 2013;347:f6800
  1. R A Benson, vascular research fellow1,
  2. R Palin, general practitioner 2,
  3. P J E Holt, senior lecturer, honorary consultant in vascular surgery3,
  4. I M Loftus, consultant/reader in vascular surgery1
  1. 1St George’s Vascular Institute, St George’s Hospital, London SW17 0QT, UK
  2. 2East Leicestershire and Rutland Clinical Commissioning Group, Leicester, UK
  3. 3Department of Outcomes Research, St George’s Hospital, London, UK
  1. Correspondence to: R A Benson ruth.benson{at}
  • Accepted 4 November 2013

Summary points

  • The prevalence of hyperhidrosis is estimated at 1%, but it is probably much higher owing to low levels of reporting to primary care

  • Onset tends to be at puberty, when axillary apocrine glands start to function, making axillary hyperhidrosis the most common type

  • Although prevalence is equal among the sexes, women are more likely to present to primary practice

  • Initial treatment in primary care should include lifestyle and behavioural advice and topical agents

  • If this approach does not work, refer to a dermatologist

  • Sympathectomy is reserved for people in whom conservative measures are ineffective or poorly tolerated, and who accept the risk of compensatory hyperhidrosis

Primary hyperhidrosis is characterised by sweating in excess of that needed for normal thermoregulation.1 The condition often goes unreported because of embarrassment,2 and management is hindered by a poor evidence base and lack of clinical guidelines. Anxiety about social situations and relationships, and problems with daily living, such as an inability to hold a pen at work, can affect quality of life.3 Hyperhidrosis may be associated with bromhidrosis (unpleasant odour) from the byproducts of bacteria that colonise sweaty areas.4 5 Subjective perceptions of the condition’s impact on the person’s life, and therefore its severity, can make confirmation of diagnosis and effective management challenging.6 This review aims to provide an update on identifying this condition, instigating appropriate management, and when to refer to a specialist.

Sources and selection criteria

We searched Medline, Embase, and the Cochrane database. Terms used alone and cross referenced were hyperhidrosis, botulin, iontophoresis, tumescent liposuction, oral therapy, topical therapy, and sympathectomy. We considered reviews, meta-analyses, randomised and non-randomised controlled trials, and large case series (owing to the lack of large volume trials). When possible, we used trials published within the past 10 years. The evidence for many treatments used in primary …

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