Conditions and medications that can cause excessive sweating are listed in Table 1 1, 2 and Table 2, 5 respectively. 2 There are several possible secondary causes for excessive sweating. Laboratory testing is not necessary unless history and physical examination suggest a secondary cause. 2 Requiring four criteria increases the discrimination between primary and secondary hyperhidrosis (positive predictive value = 0.99 negative predictive value = 0.85). Criteria for diagnosis include focal, visible, and excessive sweating for longer than six months without apparent cause, and at least two of the following: bilateral and symmetric sweating, impairment of daily activities, occurrence at least once per week, age of onset younger than 25 years, no occurrence during sleep, and a positive family history. There are no controlled studies on the sensitivity and specificity of the history, physical examination, or testing to accurately diagnose primary hyperhidrosis or to quantify its severity. Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies. Local microwave therapy is a newer treatment option for axillary hyperhidrosis. Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail. Iontophoresis should be considered for treating hyperhidrosis of the palms and soles. Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis. Topical glycopyrrolate is first-line treatment for craniofacial sweating. Topical aluminum chloride solution is the initial treatment in most cases of primary focal hyperhidrosis. The score can be used to guide treatment. The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication use. Primary hyperhidrosis is bilaterally symmetric, focal, excessive sweating of the axillae, palms, soles, or craniofacial region not caused by other underlying conditions. Hyperhidrosis is excessive sweating that affects patients' quality of life, resulting in social and work impairment and emotional distress.
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