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Defining and Diagnosing Primary and Secondary Hyperhidrosis
Table 1: Hyperhidrosis Disease Severity Scale Table 2: Main Causes of Generalised
Secondary Hyperhidrosis
Question: How would you rate the severity of your sweating?
1: Sweating is never noticeable and never interferes with daily activities.
Endocrine/metabolic diseases Thyrotoxicosis, diabetes,
2: Sweating is tolerable and sometimes interferes with daily activities.
hypoglycaemia, hyperpituitarism,
3: Sweating is barely tolerable and frequently interferes with daily activities.
pheochromocytoma, carcinoid syndrome,
4: Sweating is intolerable and always interferes with daily activities.
menopause, adipositas, gout
Neurological diseases Parkinson’s disease, spinal cord injury,
Note: Only severity scores of 3 and 4 should be assigned to true hyperhidrosis.
cerebrovascular accident
Figure 1: Primary Palmar Hyperhidrosis
Malignant conditions Myeloproliferative disorders, lymphomas,
especially Hodgkin’s disease
Infections Malaria, tuberculosis,
brucellosis, endocarditis
Cardiovascular diseases Congenital heart defects, heart failure,
acute myocardial infarction,
unstable angina, shock
Psychiatric diseases Depression, panic disorder,
social anxiety disorder
Drugs Cholinergics/sympathicomimetics,
antidepressants, opioid analgesics,
anti-oestrogens, many others
Toxicity Alcoholism, substance abuse (nicotine,
cocaine, heroin), poisoning (insecticides,
pesticides, herbicides, mercury,
pentachlorophenol, animal venoms,
Severity Scale) was indicated by 0.5% of respondents to the US
betel nuts, caffeine)
survey.
5
Some years ago, an Internet-based survey in France and
Germany found a similar proportion of 0.6% of participants claiming
Table 3: Main Causes of Regional and
Focal Secondary Hyperhidrosis
axillary sweating with severe impact. In accordance, an older study
published in 1977 arrived at the conclusion that approximately 0.6–1%
Thoracic tumours Pulmonary adenocarcinoma, bronchial carcinoma,
of the Israeli population have primary hyperhidrosis.
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mesothelioma, osteoma, cervical rib
Neurological diseases Spinal cord injury, peripheral neuropathies, complex
Types of Hyperhidrosis regional pain syndrome, cerebrovascular accident
Depending on whether excessive sweating can be attributed to a
Gustatory sweating Physiological result of sympathetic hyperactivity,
known cause, primary and secondary hyperhidrosis can be
peripheral autonomic and sensory neuropathy,
differentiated. On the basis of the extent of the area or areas affected,
parotitis, parotid abscess, Frey syndrome
hyperhidrosis can be further classified as generalised, regional or
Compensatory sweating After thoracic sympathectomy, diabetic
neuropathy, Ross syndrome, lesions in the
localised (focal). PFH is always focal, whereas secondary hyperhidrosis
spinal cord or sympathetic trunk,
is mainly generalised and less often regional or localised.
widespread sweat retention
Skin diseases Organoid nevi, eccrine and angiomatous tumours,
Primary Focal Hyperhidrosis
POEMS syndrome, burning feet syndrome,
An important step forwards in the understanding of PFH was made in
palmo–plantar keratoderma, pachydermoperiostosis,
2004 when the results of a consensus conference of an international, dyskeratosis congenita, around leg ulcers,
multidisciplinary working group on the recognition, diagnosis and in amputation stumps
treatment of this frequent condition were published.
7
PFH was
characterised as a disorder of excessive, bilateral and relatively Impairment of Daily Activities
symmetrical sweating occurring in at least one predilection site PFH affects many fields of daily life to a significant extent. Patients have
(axillae, palms, soles and craniofacial region; see Figure 1), and difficulty with manual work, such as writing, drawing, knitting and
resulting in occupational, psychological and physical impairment and playing musical instruments; pages get moistened and glass objects slip
potential social stigmatisation. The now widely accepted definition from their wet hands. Electricians and mechanics suffer electrical
includes focal, visible, excessive sweating of at least six months’ shocks and metallic instruments are corroded. Clothing and shoes are
duration without apparent cause with at least two of the six soaked with sweat and have to be changed frequently or are ruined,
characteristics outlined below. which can also cause a financial burden. Sufferers avoid handshakes,
social interaction and leisure activities and intimate relationships are
Bilateral and Relatively Symmetrical Sweating hindered. Low self-esteem and a lack of self-confidence can lead to
According to our own study up to one-fifth of patients say that the reclusiveness, frustration, unhappiness and depression.
8
sweating predominates on one side, but PFH is never unilateral. The
four predilection sites may be affected either alone or in various Total scores from the Dermatology Life Quality Index in hyperhidrosis
combinations, the axillae and palms being the most frequently patients show at least the same level of interference as reported for
involved and the most troublesome localisations. Exceptionally, other other severe dermatological diseases assumed to impose a physical
sites such as the groin may be involved, but virtually always in and/or psychological burden, such as psoriasis, pruritus/prurigo and
combination with one or more of the classic sites. acne. As a disease-specific instrument, the Hyperhidrosis Impact
EUROPEAN DERMATOLOGY 83
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