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Hyperhidrosis describes sweating in excess of normal body temperature regulation. It can be classified by its location (focal or generalised) and by the presence of an underlying cause (primary or secondary). The condition appears to improve with age and is uncommon in the elderly.
Focal hyperhidrosis commonly affects the axillae, palms, and soles.
Initial management focuses on self-care management strategies and the use of topical aluminium salts – please see Formulary, Chapter 13. Skin: Management of hyperhidrosis.
Secondary hyperhidrosis occurs due to an underlying medical condition or as a side effect of a drug or surgical intervention. Cases are usually generalised, affecting the entire skin surface. Treatment focuses on identification and management of underlying causes. Oral anticholinergic drugs can be considered as an additional management strategy.
Botulinum toxin A is commissioned for management of axillary hyperhidrosis for patients with:
Most cases of focal hyperhidrosis are idiopathic, with a possible genetic predisposition. Most commonly affected areas are the axillae, palms, and soles. There are no standardised diagnostic criteria for focal hyperhidrosis, and the diagnosis is based on history and physical signs.
The use of the Hyperhidrosis Disease Severity Scale is accepted as a means of categorising the clinical severity of hyperhidrosis in primary care.
Hyperhidrosis Disease Severity Scale | |
---|---|
My sweating is never noticeable and interferes with daily activities | Score 1 |
My sweating is tolerable but sometimes interferes with daily activities | Score 2 |
My sweating is barely tolerable and frequently interferes with daily activities | Score 3 |
My sweating is intolerable and always interferes with my daily activities | Score 4 |
Formulary, Chapter 13. Skin: Management of hyperhidrosis
Primary focal hyperhidrosis
Initial management focuses on self-care management strategies and the use of topical aluminium salts.
Self-care management strategies include:
Please note iontophoresis is no longer available in secondary care.
Aluminium Chloride preparations can cause irritation leading to discontinuation of treatment. This can be prevented in some cases by ensuring the skin is completely dry before application, and irritant dermatitis can be treated with a mildly potent topical steroid.
Consider treatment with an oral systemic anticholinergic where there is an inadequate response to at least 6 weeks of treatment with a topical aluminium antiperspirant and self-care management strategies. Where tolerated, topical aluminium products can be continued alongside oral treatment.
If response is inadequate after at least 6 weeks at the maximum tolerated dose of oxybutynin or propantheline, or treatment cannot be tolerated, consider making an Advice and Guidance request to Dermatology.
Botulinum toxin A is commissioned by NHS Devon for patients with severe axillary hyperhidrosis. Patients must have:
In severe cases which are unresponsive to these treatments, surgical intervention can be considered. However, the procedure (endoscopic thoracic sympathectomy) often leads to compensatory hyperhidrosis and so is rarely used in practice.
Please note iontophoresis is no longer available in secondary care.
Secondary hyperhidrosis
Initial management should focus on the identification and management of underlying causes. For patients with moderate to severe hyperhidrosis (HDSS score of 3 or 4) where symptoms persist despite the management of underlying causes, consider oral treatment with a systemic anticholinergic drug.
Where response is inadequate after at least 6 weeks at the maximum tolerated dose, or treatment cannot be tolerated, consider making an Advice and Guidance request to Dermatology.
Consider an Advice and Guidance request to Dermatology for patients with focal or secondary hyperhidrosis who:
Focal hyperhidrosis
Consider Dermatology referral for patients with severe focal hyperhidrosis who have failed to respond to self-care and at least 6 weeks topical aluminium chloride.
Referral Criteria:
Botulinum toxin A is only commissioned for use in patients with severe axillary hyperhidrosis. Patients must satisfy the above referral criteria AND have a resting sweat production of at least 100mg/5 minutes (per axilla).
In severe cases which are unresponsive to these treatments, surgical intervention can be considered. However, the procedure (endoscopic thoracic sympathectomy) often leads to compensatory hyperhidrosis and so is rarely used in practice.
Please note iontophoresis is no longer available in secondary care.
Generalised hyperhidrosis
Consider referral to Dermatology for patients with generalised hyperhidrosis where:
NHS Devon commissioning policy for Botulinum Toxin A for the management of focal hyperhidrosis
Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of NHS Devon upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.
MyHealth patient information - Hyperhidrosis
North and East Devon formulary - Skin
The Primary Care Dermatology Society.
This guideline has been signed off on behalf of NHS Devon.
Publication date: 30 January 2017
Updated: 16 November 2023 (In line with the NHS Devon Commissioning policy)