Hyperhidrosis: Diagnosis and treatment

If you’re living with excessive sweating, treatment can improve your quality of life. Effective treatment begins with an accurate diagnosis, which tells you the type of hyperhidrosis you have.

Here’s what you can expect when you see a board-certified dermatologist.

How do dermatologists diagnose hyperhidrosis?

To find out if you have hyperhidrosis, your dermatologist will ask you questions. Before your appointment, it’s helpful to make sure you can answer the following:

• What medications, both prescription and non-prescription, do you take?

• How long have you had excessive sweating?

• How often do you sweat excessively, such as on most days of the week or in certain situations?

• What parts of your body sweat excessively?

• Does any blood relative have/had excessive sweating?

• How is excessive sweating affecting your life?

To give you an accurate diagnosis, you may need a physical exam, medical testing, or both. These can find some possible causes of your excessive sweating.

Once your dermatologist has all the necessary information, they will talk with you about your condition.

How do dermatologists treat hyperhidrosis?

The goal of treatment is to:

• Reduce sweating so that it no longer interferes with your everyday life.

For some patients, this will mean that they can hold a pen or mouse without it slipping out of their hand. For others, it could mean wearing a shirt without developing wetness around the underarms and an unpleasant odor.

There is no single best treatment for hyperhidrosis. Your dermatologist will customize your treatment plan to your needs.

If you’ve been diagnosed with secondary hyperhidrosis, which is caused by medication or having another medical condition, your dermatologist may recommend one of the following to prevent excessive sweating:

• Work with the doctor who prescribed the medication to see if it’s possible to change medications.

• Treat the medical condition causing the excessive sweating.

If you have secondary hyperhidrosis, you may also need treatment for hyperhidrosis.

Patients diagnosed with primary hyperhidrosis (not due to a medication or medical condition) require treatment to control excessive sweating.

To treat hyperhidrosis, your dermatologist will create an individualized treatment plan based on:

• The type of hyperhidrosis you have

• Your symptoms

• Where on your body you sweat heavily

• Your preferences for treatment

Your treatment plan may include one or more of the following:

Treatment you apply to your skin

Treatment often begins with this type of therapy. The more commonly used topical (applied to the skin) treatments are:

Antiperspirant (underarms, hands, feet, back, chest, face, groin): An antiperspirant temporarily blocks your sweat glands, which can reduce the amount of sweat you see. Keep in mind that non-prescription antiperspirants are only effective for treating mild hyperhidrosis. Many patients need a prescription antiperspirant.

If an antiperspirant is part of your treatment plan, you would apply it to dry skin before bedtime. Let the antiperspirant dry completely before going to bed. Applying to dry skin reduces the likelihood of developing irritated skin.

You will continue to use the antiperspirant at bedtime until the excessive sweating is under control. This usually happens within a few weeks. To keep the excessive sweating under control, you continue to apply the antiperspirant as needed, which is usually once or twice a week.

When using an antiperspirant, some people develop irritated skin or underarm discoloration. If you develop either, tell your dermatologist. There are many effective ways to calm these. For irritated skin, these include increasing the amount of time between applications, using a different formulation like a gel, or making sure that your skin is very dry before you apply.

• Brand names (prescription antiperspirants): Drysol, Hypercare, Xerac AC

Glycopyrronium (glye-co-pie-row-nee-um) medicated cloth (underarms): This prescription medication can make your body produce less sweat. To use it, you take one pre-moistened medicated cloth from the package and wipe the cloth on both underarms. You do this once a day.

The United States Food and Drug Administration (FDA) approved this medicated cloth to treat primary hyperhidrosis in the underarms. It’s approved to treat people who are 9 years of age and older.

When using this medication, you can also use an antiperspirant (reduces sweat) or deodorant (reduces odor) on your underarms if you wish.

After using this medicated cloth, immediately throw it away and wash your hands. It’s important to dispose of this cloth in such a way that children, pets, and other people cannot get to it. You also need to thoroughly wash your hands with soap and water.

If you accidentally get the medication from the cloth on your face or in an eye, you can develop side effects like irritated skin or blurry vision. These are temporary and will go away if you avoid getting the medication in these areas.

The most common side effects are dry mouth, dilated pupils (makes eyes sensitive to sunlight and bright light), sore throat, and irritated underarm skin.

• Brand name: Qbrexza

Sofprionium (sof-peh-row-nee-um) gel (underarms): This prescription medication works by reducing how much sweat your body can make.

The FDA approved this medicated gel to treat people 9 years of age and older who have primary hyperhidrosis in their underarms.

You apply this medication to your underarms before going to bed. You do this every day, applying it to dry underarms. Applying it to dry underarms reduces the chance of developing irritated skin. If you’ve just taken a shower or washed your underarms, wait 30 minutes before applying this medication.

After applying this medication, immediately wash your hands with soap and water. It’s also important that you do not touch the skin where you’ve applied sofprionium. If this medication gets on your hands and accidentally touches an eye or the skin around your eyes, you can develop blurry vision. This is temporary and will go away.

The most common side effects are dry mouth, dilated pupils (makes eyes sensitive to sunlight and bright light), and irritated underarm skin.

• Brand name: Sofdra

Procedures and energy-based treatments

If one of these is right for you, you would either receive treatment in your dermatologist’s office or perform the treatment at home.

Botulinum toxin injections (underarms, hands, feet, face): You may recognize this as a treatment for temporarily reducing wrinkles like crow’s feet and frown lines. It’s also FDA approved to treat hyperhidrosis.

Botulinum toxin treats excessive sweating by temporarily reducing the amount of sweat where it’s injected. Dermatologists use it to treat excessive sweating in patients’ underarms, hands, feet, and face.

Most patients notice less sweating within 7 to 10 days of being treated.

Here’s how long the results tend to last:

• Underarms or hands: 3 to 10 months

• Feet: 3 to 6 months

• Face: 4 1/2 months

Before getting these injections, it’s essential to stop taking aspirin and some other anti-inflammatory medications, as well as vitamin E. Doing so helps reduce the likelihood of developing bruises or bleeding.

Studies show that botulinum toxin can be a safe and effective treatment for excessive sweating. The most common side effects are pain, bruising, headache, muscle soreness or weakness where injected, and mild itching.

• Brand name: Botox

Iontophoresis (eye-an-tuh-fuh-ree-sus) machine (hands and feet): This device is also called a “portable anti-sweat machine.”

To use it, you place your hands or feet in a pan of tap water. A direct electric current goes into the water and enters the surface of the skin, which can reduce the amount of sweat that the treated area can make.

Your dermatologist may recommend adding a medication to the water that can further help prevent excessive sweating.

The FDA has cleared this machine to treat hyperhidrosis on the hands and feet. Some patients use a special electrode to treat their underarms, but this tends to be less effective.

In the beginning, patients usually treat for 20 to 30 minutes. Treatment may be daily or once every 2 to 5 days. You continue treating this often until you see noticeably less sweating, which usually occurs after 5 to 10 treatments.

Once you have noticeably less sweating, most patients can maintain their results by treating once a week or every other week.

This patient is using an iontophoresis machine to treat excessive sweating

If iontophoresis is right for you, you can buy a machine to use at home.

Possible side effects while using the machine include mild discomfort like burning or a tingling sensation. If used incorrectly, a mild burn can develop.

Microwave thermolysis (ther-moe-lie-sis) (underarms): This is a procedure that your dermatologist performs in the office, using a device that destroys sweat glands with heat. This, in turn, reduces excessive sweating.

The device destroys sweat glands in 1 or 2 office visits. Once sweat glands are destroyed, you see immediate results.

The FDA has cleared this device to treat hyperhidrosis in the underarms. Studies show that it can also get rid of underarm odor and hair.

This treatment can give patients long-lasting results. However, it is expensive and not covered by most health insurance plans.

Possible side effects include temporary discomfort, underarm swelling, discoloration, and tenderness. These usually go away within 4 weeks of getting treated.

More serious possible side effects include burns and neuropathy (lasting nerve pain). You can reduce your risk of developing more serious side effects by partnering with a board-certified dermatologist. These doctors understand the skin and what lies beneath it.

Sweat-control patch (underarms): The FDA cleared this patch to treat hyperhidrosis in the underarms of people 18 years of age and older.

The patch is applied in your dermatologist’s office and left in place for no longer than 3 minutes. When the patch is applied, the sodium in the patch interacts with the water in your sweat. This causes the area to heat up, which injures sweat glands.

This injury inactivates the sweat glands for 2 to 4 months. Most people see results in approximately 3 to 5 days after treatment.

After treatment, your underarms may feel irritated, tender, or sensitive. These feelings tend to go away quickly.

Medication that works throughout your body

Several different oral (take by mouth) medications can be used. An oral medication may be in your treatment plan if:

• Other treatments have failed to work.

• Another treatment is needed to improve the results from other treatments.

• You have excessive sweating in several areas or over most of your body.

• Other treatments like botulinum toxin or iontophoresis control excessive sweating in certain areas, but you have uncontrolled sweating in other areas like the groin, face, or beneath the breasts.

These medications include:

Oral glycopyrronium or oral oxybutynin (ox-e-bue-ti-nin) (body wide): These medications work throughout the body to reduce the ability of sweat glands to produce sweat.

Some people take one of these oral medications to temporarily reduce excessive sweating before an event like giving a speech or standing up for a wedding.

Your dermatologist will tailor the dosage to meet your needs. You may start at a low dose, and your dermatologist may increase the dose over time. To continue seeing results, you must continue taking the medication. Your dermatologist will keep you on the lowest dose needed to see results.

Possible side effects include dry mouth (most common), constipation, drowsiness, dilated pupils (makes skin sensitive to light), blurred vision, headache, and being unable to fully empty your bladder.

When taking one of these medications, it’s essential to avoid hot temperatures since decreased sweating can make it difficult for your body to cool itself. A fever or heat stroke can occur if your body cannot cool itself.

• Brand names (oral glycopyrronium): Cuvposa, Glycate, Robinul, and Robinul-Forte

• Brand names (oral oxybutynin): Ditropan XL [DSC] and Oxytrol

Propranolol (pro-PRAN-oh-lol) (excessive sweating due to anxiety or stress): Do you only sweat excessively when you become anxious or feel stressed? Taking a low dose of propranolol before an event can prevent excessive sweating. People take it when sweating may interfere with their performance, such as during a job interview or while giving a speech.

Propranolol works by slowing down your heart rate, which can help reduce sweating due to feeling anxious or nervous.

You take this medication 30 to 60 minutes before the event. It is not to be taken on a regular basis due to possible side effects.

Propranolol belongs to a class of medications called beta blockers. These medications are used to treat high blood pressure, so they affect your heart and how blood flows through your arteries and veins.

• Brand names (propranolol): Hemangeol, Inderal LA, Inderal XL, InnoPran XL

Before you take medication, your dermatologist will talk with you about the prescribed medication, how to take it, and what to watch for.

Surgery to treat hyperhidrosis

If other treatments fail to bring relief, surgery may be considered. Surgery can permanently stop excessive sweating in the treated area. When surgery is an option, your dermatologist will refer you to a surgeon.

A possible side effect of surgery is “compensatory sweating.” This means that while you’ll no longer sweat in the area where you had surgery, the body compensates by sweating in other areas. Most patients have some degree of compensatory sweating, which ranges from mild to heavy. It’s possible to sweat more heavily in other areas than you previously did in the area treated with surgery.

The surgical treatments most often used to treat hyperhidrosis are:

Sweat gland removal (underarms): Sweat glands can be removed from the underarms in several ways. Your surgeon may use:

• Curettage (scrape away)

• Liposuction (suction out)

• Laser surgery (destroy with a laser)

• Surgical excision (cut out)

• Combination of two or more of the above procedures

Sweat gland removal has possible side effects, which include scarring, pain, bleeding, and infection.

Sympathectomy (palms, underarms): This surgery is performed in an operating room while the patient is under general anesthesia.Today, it is considered minimally invasive because surgeons make small incisions (cuts) to get into the area to be treated. Surgeons typically use video to guide them to the area they’ll treat. Many patients go home the same day.

During this surgery, the surgeon cuts or removes nerves going to the palms or underarms. This interrupts signals that the nervous system sends to affected sweat glands. Without these signals, the body cannot produce sweat in the area treated.

The most common side effect is compensatory sweating. It develops with time and usually occurs on the belly, legs, or back. Many patients say they prefer sweating in these areas to having excessively sweaty palms or underarms.

Other possible side effects include excessive dryness in the area treated and a return of excessive sweating.

Your dermatologist knows hyperhidrosis

With a dermatologist’s help, you don’t need to live with excessive sweating. Your dermatologist knows how to create a treatment plan that can reduce hyperhidrosis. Your plan may consist of one treatment or a combination of treatments.

To help patients get the best results from treatment, dermatologists include self-care in a treatment plan. To find out what dermatologists recommend for people who sweat heavily, go to Hyperhidrosis: 6 tips dermatologists give their patients.

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Written by:
Paula Ludmann, MS

Reviewed by:
Elizabeth Damstetter, MD, FAAD
Neelam Khan, MD, FAAD
William Warren Kwan, MD, FAAD
Temitayo A. Ogunleye, MD, FAAD
Sanna Ronkainen, MD, FAAD

Last updated: 7/16/24