How to manage hyperhidrosis in primary care

Hyperhidrosis is a condition characterised by excessive sweating beyond thermoregulatory needs. It affects two to three per cent of the population. Although not a life-threatening disease, hyperhidrosis can significantly impair quality of life, leading to social anxiety, occupational difficulties, and skin complications.

GPs are often the first point of contact for patients concerned about excessive sweating, and play a key role in diagnosis, initial management, and appropriate referral.

Classification and diagnosis

We can differentiate between the two types of hyperhidrosis. These are primary, or focal hyperhidrosis, and secondary, or generalised hyperhidrosis.

Primary hyperhidrosis usually starts in childhood or adolescence, with no underlying systemic disease. The symptoms are commonly localised to palms, soles, axillae, or face, and are absent during sleep. Their presentation is symmetric.

Secondary hyperhidrosis develops as a result of systemic conditions, medications, or neurologic disorders. The presentation can be generalised or localised, and it often occurs during sleep.

History taking

The patient's medical history helps us determine the type and duration of hyperhidrosis. For example, a childhood onset suggests primary, while a sudden onset in adulthood suggests secondary hyperhidrosis.

Other important information to obtain while taking history includes:

• Distribution: Symmetrical vs asymmetrical. Focal vs generalised.
• Triggers, such as heat, stress, spicy food, or physical activity.
• Impact on quality of life, such as social, emotional, and occupational limitations due to hyperhidrosis.
• Associated symptoms include weight loss, palpitations, fever, flushing (consider secondary causes).
• Medications review, because SSRIs, insulin, opioids, and cholinergic drugs can cause sweating.

Physical examination

A GP should inspect and palpate the affected areas. The goal is to look for skin changes, such as maceration, dermatitis, or signs of infection.

Also, it is important to measure the BMI and vital signs, and consider Minor’s starch-iodine test for severity mapping if necessary.

Initial investigations

Primary hyperhidrosis with a classic presentation typically does not require any laboratory tests. For secondary hyperhidrosis, the following tests are advised:

• CBC, ESR/CRP
• TSH, fasting glucose/HbA1c
• Liver and renal function tests
• HIV test if risk factors present
• Consider chest X-ray or other imaging if clinically indicated

Management strategy

When managing hyperhidrosis in a primary care setting, some general principles apply:

• Address secondary causes first
• Begin with the least invasive measures
• Use a stepwise escalation based on symptom severity and patient response

First-line therapy

Topical aluminum chloride hexahydrate (20%) is the first-line therapy for hyperhidrosis. Patients should apply it nightly to dry skin and wash off in the morning.

Once the sweating is under control, reduce to maintenance (one to two times weekly). Some side effects, such as irritation, are possible (can be reduced with hydrocortisone cream).

Some lifestyle and self-care tips that can help include:

• Wear loose, breathable clothing
• Choose moisture-wicking socks and change often
• Use absorbent shoe inserts or armpit pads
• Avoid known triggers (e.g., caffeine, spicy foods).
• Maintain good hydration

Second-line therapy

Second-line therapy for hyperhidrosis in primary care may include:

• Topical anticholinergics
• Glycopyrronium cloths or creams (FDA-approved for axillary hyperhidrosis)
• Oxybutynin gel
• Oral anticholinergics: oxybutynin (2.5–10 mg/day) or glycopyrrolate (1–2 mg BID)

It is vital to monitor for side effects, such as dry mouth, constipation, blurred vision, and urinary retention. Also, use caution in elderly patients.

Third-line therapy

Botulinum toxin type A injections are an effective solution for axillary, palmar, and plantar hyperhidrosis. The effects of the treatment typically last four to six months.

For refractory cases, systemic medications, such as beta-blockers (for anxiety-triggered sweating) or clonidine for generalised sweating with flushing, may be considered

When to refer

Refractory symptoms after primary care treatment, an unclear diagnosis, or suspicion of secondary cause requiring specialist work-up, or surgical (advanced) interventions call for a specialist referral. Consider dermatology, neurology, endocrinology, or surgery based on findings.

With adequate training, GPs should be able to differentiate primary from secondary hyperhidrosis before starting therapy. First-line treatment begins with topical agents, but may escalate stepwise. It is pivotal to address the psychosocial impact early, and refer the patient appropriately for advanced therapies.

 – Dr Rosmy De Barros

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References

• Parashar, K., Adlam, T., & Potts, G. (2023). The impact of hyperhidrosis on quality of life: a review of the literature. American Journal of Clinical Dermatology, 24(2), 187-198.
• Stuart, M. E., Strite, S. A., & Gillard, K. K. (2021). A systematic evidence-based review of treatments for primary hyperhidrosis. Journal of drug assessment, 10(1), 35-50.
• Behinaein, P., Gavagan, K., Waitzman, J., Pourang, A., & Potts, G. (2025). A review of the etiologies and key clinical features of secondary hyperhidrosis. American Journal of Clinical Dermatology, 26(1), 97-108.
• Nawrocki, S. (2019). Diagnosis and qualitative identification of hyperhidrosis. Shanghai Chest, 3.
• Henning, M. A., Bouazzi, D., & Jemec, G. B. (2022). Treatment of hyperhidrosis: an update. American journal of clinical dermatology, 23(5), 635-646.
• Campanati, A., Gregoriou, S., Milia-Argyti, A., Kontochristopoulos, G., Radi, G., Diotallevi, F., ... & Offidani, A. (2022). The pharmacological treatment and management of hyperhidrosis. Expert Opinion on Pharmacotherapy, 23(10), 1217-1231.
• Hoverson, K., & Kandula, P. (2020). Hyperhidrosis: a review and treatment options. Advances in Cosmetic Surgery, 3(1), 155-163.
• Castiglione, L., Murariu, M., Boeriu, E., & Enatescu, I. (2024). Assessing botulinum toxin effectiveness and quality of life in axillary hyperhidrosis: a one-year prospective study. Diseases, 12(1), 15.