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Primary Hyperhidrosis: A Review of Epidemiology, Pathophysiology and Management

Acta Derm Venereol. 2026 Sep 16;106. doi: 10.2340/actadv.v106.adv-2026-0770.

ABSTRACT

Primary hyperhidrosis is termed as excessive sweating exceeding the physiological needs of thermoregulation. This review provides an updated overview focusing on epidemiology, quality of life, pathophysiology, economic impacts, diagnostic approaches and current management strategies. A literature search was conducted in June 2026 across PubMed and the Cochrane Central Register of Controlled Trials. Additional references were identified through manual searches of relevant bibliographies. Reported prevalence of hyperhidrosis varied widely, likely reflecting differences in methodology and disease recognition. Primary hyperhidrosis is associated with autonomic dys-regulation involving sympathetic pathways. Emerging evidence suggests that molecular alterations in eccrine glands may represent secondary adap-tations to sustained cholinergic stimulation, while genetic variability in receptor expression may contribute to interindividual differences in disease severity. Hyperhidrosis has a strong negative impact on the economy and quality of life, adversely affecting both mental and physical health. Multiple treatment options are available, including topical therapies, systemic agents, device-based interventions, botulinum toxin injections, and surgery. Despite increasing recognition of the clinical burden, comprehensive economic evaluations remain limited, with indirect costs and long-term societal impact insufficiently characterized. In conclusion, primary hyperhidrosis imposes a substantial burden on affected individuals, requiring improved re-cognition, standardized diagnostic frameworks, and individualized management strategies supported by high-quality and longitudinal research.

PMID:42747166 | DOI:10.2340/actadv.v106.adv-2026-0770

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A 1% glycopyrronium bromide cream for topical treatment of severe primary axillary hyperhidrosis in adolescents: safety, local tolerability, systemic exposure and efficacy from an open-label phase II study

J Dtsch Dermatol Ges. 2026 Sep 15. doi: 10.1111/ddg.70469. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Primary axillary hyperhidrosis (PAHH) results from dysregulation of the autonomic nervous system and typically begins during puberty. Treatment options for adolescents remain limited. This open-label phase II study evaluated the safety, local tolerability, systemic exposure, and efficacy of 1% GPB cream over 8 weeks in adolescents with severe PAHH.

PATIENTS AND METHODS: A total of 42 adolescents (23 male [55%] and 19 female [45%]; aged 12-17 years) applied the cream once daily for the first 4 weeks and thereafter as needed (at least twice weekly but no more than once daily). The primary endpoints assessed adverse drug reactions (ADRs), local tolerability, and systemic glycopyrronium exposure. Changes in sweat production, PAHH severity, and quality of life were assessed in all patients.

RESULTS: Two patients experienced mild ADRs (dry eye and increased conjugated bilirubin in one patient each); no serious adverse events occurred. All 40 evaluable patients had a skin reaction score of 0 throughout treatment. Total sweat production decreased significantly from baseline to day 29 (p < 0.001) and day 57 (p < 0.001). Patient-rated hyperhidrosis severity (PRHS) and quality of life, assessed using the Children’s Dermatology Life Quality Index (CDLQI), also improved significantly at both time points (all p < 0.001).

CONCLUSIONS: 1% GPB cream showed favorable safety and tolerability and improved clinical outcomes in adolescents with severe PAHH, consistent with findings in adults.

PMID:42745527 | DOI:10.1111/ddg.70469

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Persistent Hyperhidrosis in the Psychiatric Setting: A Case Report

Cureus. 2026 Aug 11;18(8):e114349. doi: 10.7759/cureus.114349. eCollection 2026 Aug.

ABSTRACT

Hyperhidrosis, defined as excessive sweating beyond what is required for thermoregulation, is a recognized adverse effect of numerous medications, including several classes of psychotropic agents acting through different mechanisms. We present the case of a 43-year-old male with a complex psychiatric and medication history who developed persistent, drenching night sweats that continued despite multiple psychotropic medication adjustments and discontinuations. Alternative metabolic, infectious, endocrine, and substance-related causes were considered without identification of a clear etiology. This case highlights the difficulty of attributing hyperhidrosis to a single agent in patients with complex medication histories and emphasizes the importance of balancing symptom management with the continuation of necessary psychiatric treatment.

PMID:42725212 | PMC:PMC13561136 | DOI:10.7759/cureus.114349

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Efficacy and safety of rib-guided percutaneous thoracic sympathetic radiofrequency thermocoagulation at two different targets for primary palmar hyperhidrosis: a randomized controlled trial

Ann Med. 2026 Dec;58(1):2717461. doi: 10.1080/07853890.2026.2717461. Epub 2026 Aug 26.

ABSTRACT

OBJECTIVES: To compare the efficacy and safety of computed tomography-guided percutaneous thoracic sympathetic radiofrequency thermocoagulation (RFT) targeting the upper versus lateral margin of the fourth rib head for severe primary palmar hyperhidrosis (PPH).

METHODS: Patients with severe PPH were randomly divided into Group U (upper margin target) and Group L (lateral margin target). Outcome measures included 1-year recurrence rate, Hyperhidrosis Disease Severity Scale (HDSS), Dermatology Life Quality Index (DLQI), palm skin temperature, finger perfusion index (PI), compensatory hyperhidrosis and patient satisfaction.

RESULTS: Both groups (n = 55 each, 110 sides) successfully underwent RFT. No preprocedural PI differences were found (p > 0.05). Immediately post-RFT, PI in Group L was significantly higher than in Group U (left p = 0.025, right p = 0.013). No significant differences in HDSS grades were observed between groups before and at 1 day, 2 weeks, 1 month and 3 months post-procedure. However, at 6 and 12 months, Group L showed significantly lower HDSS grades (left p = 0.033 and 0.016; right p = 0.039 and 0.025) and lower DLQI scores (p = 0.037 and 0.024) than Group U. Patient satisfaction did not differ within 6 months, but Group L had significantly higher satisfaction at 12 months (p = 0.036).

CONCLUSIONS: Targeting the lateral margin of the fourth rib head for RFT achieved greater efficacy, better quality of life and higher patient satisfaction compared to the upper margin target.

PMID:42647852 | DOI:10.1080/07853890.2026.2717461

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Botulinum toxin A for primary axillary hyperhidrosis: a narrative review

J Med Life. 2026 Jun;19(6):420-425. doi: 10.25122/jml-2026-0005.

ABSTRACT

Primary axillary hyperhidrosis (PAH) markedly impairs psychosocial well-being and daily functioning. Botulinum toxin type A (BoNT-A) is widely used, both on- and off-label, to suppress eccrine sweating through presynaptic inhibition of acetylcholine release and temporary chemodenervation of cholinergic sympathetic fibers. This narrative review synthesizes published clinical evidence between 2000 and January 2025 regarding the efficacy, durability, safety, and quality-of-life outcomes of BoNT-A for PAH, with comparative consideration of toxin formulations, injection techniques, and device-based alternatives. Evidence from randomized trials, prospective cohorts, long-term observational studies, and meta-analyses consistently demonstrates that intradermal BoNT-A achieves substantial axillary sweat reduction, often exceeding 50-80%, with improvement of at least two grades on the Hyperhidrosis Disease Severity Scale and meaningful reductions in Dermatology Life Quality Index scores. Treatment effects typically persist for approximately 4-7 months per cycle and are associated with predominantly mild, localized adverse events. Comparative data indicate similar efficacy among onabotulinumtoxinA, incobotulinumtoxinA, and abobotulinumtoxinA when equivalent dosing and standardized mapping techniques are applied. Injection strategy, particularly multi-point intradermal delivery guided by starch-iodine mapping, influences coverage and durability. Energy-based modalities-including microwave thermolysis and fractional microneedle radiofrequency-reduce sweating via device-mediated thermal targeting of eccrine glands and show variable comparative outcomes versus intradermal BoNT-A in durability, downtime, and cost. Overall, BoNT-A remains a well-supported first-line injectable therapy for PAH refractory to topical treatment, while further head-to-head and cost-effectiveness studies remain warranted.

PMID:42602382 | PMC:PMC13474375 | DOI:10.25122/jml-2026-0005

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Associations between Primary Hyperhidrosis and Psychiatric Conditions: A Matched Case-Control Study of 8,508 Patients

Skin Appendage Disord. 2026 Jun 27. doi: 10.1159/000553303. Online ahead of print.

ABSTRACT

INTRODUCTION: Primary hyperhidrosis (PHH) is defined by excess sweating not attributable to medications or underlying medical conditions. It is associated with significant burden of subsequent psychiatric comorbidities, but psychiatric conditions preceding PHH diagnosis are not well characterized. We assessed associations of PHH with preceding psychiatric conditions using a matched case-control approach.

METHODS: Overall, 1,418 participants with PHH and 7,090 matched controls were assessed using the All of Us Research Program database. Multivariable logistic regressions calculated odds ratios and 95% confidence intervals, with Benjamini-Hochberg correction for multiple testing.

RESULTS: Subjects with PHH vs. controls had higher odds of prior diagnosis with obsessive-compulsive disorder (OCD) (OR: 1.97, 95% CI: 1.29-2.94, corrected p = 0.007), restless legs syndrome (RLS) (OR: 1.63, 95% CI: 1.22-2.15, corrected p = 0.007), attention-deficit/hyperactivity disorder (ADHD) (OR: 1.35, 95% CI: 1.07-1.69, corrected p = 0.035), and insomnia (OR: 1.22, 95% CI: 1.04-1.44, corrected p = 0.037).

CONCLUSION: We found significant associations with subsequent PHH diagnosis in participants with OCD, ADHD, RLS, and insomnia. Further research into the etiologies of psychiatric conditions and PHH may better elucidate their relationship.

PMID:42583460 | PMC:PMC13461199 | DOI:10.1159/000553303

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Real-World Outcomes of Microwave Treatment for Axillary Hyperhidrosis and Bromhidrosis: A 12-Month Study in a Southeast Asian Setting

Clin Cosmet Investig Dermatol. 2026 Jul 25;19:617844. doi: 10.2147/CCID.S617844. eCollection 2026.

ABSTRACT

BACKGROUND: Microwave therapy has emerged as a minimally invasive treatment option, but long-term real-world data, particularly from Southeast Asian populations, remain limited.

PURPOSE: To evaluate the effectiveness of microwave therapy and its impact on quality of life (QoL) in patients with axillary hyperhidrosis and bromhidrosis.

PATIENTS AND METHODS: A longitudinal ambispective case series study was conducted on 52 adult patients with axillary hyperhidrosis and bromhidrosis treated with microwave therapy. Treatment efficacy and QoL improvement were assessed at 1 week and at 3, 6, 9, and 12 months post-intervention using the Minor test, Hyperhidrosis Disease Severity Scale (HDSS), Visual Analog Scale (VAS), and Dermatology Life Quality Index (DLQI). Repeated measures were analyzed using mixed-effects models.

RESULTS: At 1 week, the mean area of discoloration decreased markedly from 49.1 cm2 to 0.3 cm2 in the left axilla, with similar improvement observed in the right axilla. At 12 months, compared with baseline, the model-predicted probability of HDSS grade 4 decreased from 68.2% to 5.7%, while the mean odor score and DLQI score decreased from 6.8 to 3.0 and from 19.5 to 6.5, respectively. Overall satisfaction at 12 months was 66.6%. Statistically significant improvements were observed across the majority of efficacy outcomes (p < 0.05). The most common adverse events were pain and swelling, which were mild and self-limiting, with no serious complications reported.

CONCLUSION: Microwave therapy demonstrated a favorable safety profile and sustained clinical benefits in patients with axillary hyperhidrosis and bromhidrosis over 12 months of follow-up. Although patient satisfaction declined modestly at 12 months, overall treatment outcomes remained favorable.

PMID:42529744 | PMC:PMC13418893 | DOI:10.2147/CCID.S617844