Diagnosis Guidelines

The approach to diagnosis starts with using one or more methods of assessment of severity of sweating. Practical, qualitative, and quantitative methods are available to aid the physician in confirming the diagnosis. A logical approach to making a clinical diagnosis is presented, along with a diagnostic algorithm outlining this approach.

Assessment methods

During the evaluation of a patient with primary hyperhidrosis, it is sometimes necessary to assess the rate of sweat production, the specific areas involved, the effect of the condition on the patient’s quality of life, and the impairment of daily activities.

Many experts believe that it is very important to observe the patient sweating during an office visit. For axillary involvement, an assessment of the sweat stains of shirts and blouses can be useful. In some cases, a sweat stain with a diameter less than 5 cm is normal. Mild hyperhidrosis can be associated with stains 5 to 10 cm in diameter and still confined to the armpit. Stains of 10 to 20 cm are seen in moderate hyperhidrosis, while stains over 20 cm reaching the waistline are common in severe hyperhidrosis.[57] For palmar hyperhidrosis, a low grade of involvement would be a moist palmar surface without visible droplets of perspiration. If palmar sweating extends toward the fingertips, the condition can be considered moderate, and if sweat drips off the palm and reaches all the fingertips, it is severe.[57]
A quantitative approach to assessing severity is gravimetric measurement, which can be done on the palm and in the axilla. It is important to note that gravimetric measurement is often utilized in clinical trials and is not part of routine clinical practice.[57,63] After drying the surface, a preweighed filter paper is applied to the palm or axilla for a period of time measured by stopwatch. The paper is then weighed and the rate of sweat production is calculated in mg/min. Sweating rates in normal individuals and in patients with hyperhidrosis are presented in the table below. Because there is some overlap between patients and controls, the degree of embarrassment and effect on quality of life and impairment on daily activities should also be assessed in order to confirm the diagnosis.[63]

Sweating rates by gravimetric measurement

Another quantitative test is evaporimetry, in which a device measures the rate of skin water vapor loss. This test has been used to assess response to treatment by both topical therapy and botulinum toxin A injections for palmar hyperhidrosis.[44,95]

The Minor, or starch-iodine, test is used to assess the area involved in excessive sweating. [145] This test is not useful for quantifying the degree of hyperhidrosis, as there is little correlation with area of sweating and sweat rate measured by gravimetry.[54] In this method, a 2% iodine solution is applied to the area of interest and allowed to dry, and then starch in powder form (corn starch) is brushed on the area.[145] The light brown iodine color turns dark purple as an iodine-starch complex forms in the liquid medium as the eccrine sweat comes to the surface of the affected area.[57] Digital photography of the involved area allows for documentation and follow-up comparison after treatment.[43]

Printing tests using paper impregnated with starch-iodine or spraying ninhydrin on paper applied to the sweating surface work similarly, with color changes denoting area of active eccrine sweat production. These methods can provide only a qualitative assessment of sweating but are useful for following patients after treatment by serial photography of the involved areas.[95]

Another approach to assessment is the use of a quality-of-life and impairment of daily activities measurement. Possible useful instruments would include the Illness Intrusiveness Rating Scale, the Dermatology Quality of Life Index, or a disease-specific measure of quality of life such as that developed by Amir and colleagues or the HHIQ5, or the Hyperhidrosis Disease Severity Scale(HDSS).[28, 100,139] See Condition Overview: Effects on patients’ lives.

Approach to diagnosis

The first step in the evaluation of a patient's excessive sweating is to distinguish between primary and secondary hyperhidrosis, since therapy for secondary causes should be directed toward the underlying illness.[9] A history focusing on location of excessive sweating, the duration of the problem, family history, specific triggers, and a review of systems should allow the physician to distinguish whether the patient has generalized sweating due to an underlying systemic illness, focal sweating due to a neurologic disorder, or primary hyperhidrosis.[2,57,145]

Primary hyperhidrosis has such specific and characteristic findings that Adar and colleagues feel the diagnosis can be made on the basis of history and physical alone.[2] These findings include its occurrence in young, healthy patients with a family history, and onset during childhood or adolescence. Patients will have bilateral, symmetric involvement of palms, soles, and/or axillae, as well as a history for the usual triggers, emotional and thermal stimuli. Also patients with primary hyperhidrosis usually do not sweat during sleep.

Although the diagnosis can usually be made on the basis of history and observed excessive sweating, gravimetric measurement can provide a quantitative assessment.[51] Given the potential for overlap in sweating rates between patients with hyperhidrosis and healthy controls,[63] it is important to gauge the severity of social embarrassment and the effects on quality of life and impairment of daily activities in order to plan treatment, especially if more than one area is involved.[95] This information can be obtained by asking appropriate questions as part of the patient’s history and by using questionaires or patient self-rating scales.[95] 

Download printable algorithm here.