Condition
Hyperhidrosis
Editors: Shari R. Lipner MD, PhD; Ahmad M. Al Aboud MD, FAAD, MHA; Zbigniew Fedorowicz PhD, MSc, DPH, BDS, LDSRCS; Dan Randall MD, MPH, FACP
Background Information
Description
- hyperhidrosis is excessive sweating that may be focal or generalized,,,
- hyperhidrosis may or may not have an apparent underlying cause
- >90% of hyperhidrosis is primary (no known underlying cause)
- focal hyperhidrosis is more often primary (idiopathic)
- primary hyperhidrosis
- typically focal and symmetric and most frequently affecting the axillae, but may also affect the soles of the feet, palms of the hands or the face
- most commonly starts between ages 14-25 years old
- if begins prior to puberty, may be more likely to affect the hands and feet
- PubMed15632408CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienneCMAJ20050104172169-7569Reference - CMAJ 2005 Jan 4;172(1):69
- secondary hyperhidrosis
- may be focal or generalized
- caused by an underlying medical condition or medication use
- PubMed15632408CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienneCMAJ20050104172169-7569Reference - CMAJ 2005 Jan 4;172(1):69
Also called
- excessive sweating
- gustatory sweating also called
- Frey syndrome
- Baillarger syndrome
- Frey-Baillarger syndrome
- Dupuy syndrome
- auriculotemporal syndrome
Types
- classification based on identification of underlying condition,
- primary hyperhidrosis (also called idiopathic or essential hyperhidrosis) has no apparent cause
- secondary hyperhidrosis is associated with a underlying condition (see Causes)
- classification based on site(s) of excessive sweating,
- focal hyperhidrosis
- excessive sweating localized to discrete site(s)
- palmar-plantar hyperhidrosis - excessive sweating at palms of hands or soles of feet (most common type of focal hyperhidrosis in children)
- isolated axillary hyperhidrosis - excessive sweating at underarms, more common after puberty (may be concurrent with palmar-plantar hyperhidrosis)
- craniofacial hyperhidrosis - excessive sweating at face (may be caused by heat, emotion, or spicy foods [which may be referred to as gustatory hyperhidrosis])
- usually idiopathic
- excessive sweating localized to discrete site(s)
- generalized hyperhidrosis
- excessive sweating across the entire body
- usually secondary to an underlying condition
- focal hyperhidrosis
Epidemiology
Incidence/Prevalence
- hyperhidrosis affects 1%-3% of population in United States (although < 50% of affected people report symptoms to their physician)
- 2.9% prevalence of hyperhidrosis in mailed survey of 150,000 United States households, 1.4% have axillary hyperhidrosis (J Am Acad Dermatol 2004 Aug;51(2):241)
Who is most affected
Risk factors
Associated conditions
Bromhidrosis (body odor)
Overview and pathophysiology
- bromhidrosis is a chronic condition of abnormal and excessively unpleasant/offensive body odor due to excessive secretion from either apocrine or eccrine sweat glands
- also called osmidrosis, bromidrosis, ozochrotia, body odor, or malodorous sweating
- may involve all types of sweat glands; apocrine bromhidrosis (most common) occurs after puberty while eccrine bromhidrosis may occur at any age
- excessive levels of sweat become malodorous when combined with bacterial breakdown on the skin
- may be exacerbated by poor hygiene or underlying conditions associated with enhanced bacterial growth such as
- diabetes
- intertrigo
- erythrasma
- obesity
- associated with potentially significant social embarrassment
- reported to be more common in men
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483References - Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266
- apocrine bromhidrosis is more common than eccrine bromhidrosis
- apocrine glands develop with puberty, therefore apocrine bromhidrosis presents after puberty
- apocrine glands typically occur in axillae, perineum, nipples, eyelids, and ears
- sweat from the apocrine gland appears to be broken down by resident microflora, such as Corynebacterium, Staphylococcus, Micrococcus, and Propionibacterium to form malodorous ammonia and short-chain fatty acids
- Corynebacterium species, in particular, produces a specific N-alpha-acyl-glutamine aminoacylase (N-AGA) that can release odoriferous volatile acids from apocrine secretions
- a dominant pattern of inheritance for apocrine bromhidrosis has been postulated, and potential genetic factors include specific polymorphism on gene ABCC11
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483References - Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266
- eccrine bromhidrosis (less common than apocrine bromhidrosis)
- underlying associated causes/conditions of eccrine bromhidrosis include all of the following
- hyperhidrosis - mechanism is unclear, but thought to involve excess sweat creating optimal environment for bacteria overgrowth, which leads to further keratin degradation and enhanced odor
- bacterial degradation of sweat-softened keratin
- ingestion of certain types of food (such as alcohol, garlic, onion, or curry), medications (such as penicillin or bromides), or toxins
- underlying metabolic disturbances such as disturbances in amino acid metabolism, sweaty feet syndrome, cat odor syndrome, isovaleric acidemia, and hypermethioninemia
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483References - Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266
- underlying associated causes/conditions of eccrine bromhidrosis include all of the following
- PubMed1986703Archives of dermatologyArch Dermatol199101011271129129case report of severe body-broad bromhidrosis caused by impacted foreign body in right nostril of 8-year-old White boy can be found in Arch Dermatol 1991 Jan;127(1):129
Evaluation and diagnosis
- bromhidrosis is a clinical diagnosis and testing is not typically required to guide management
- consider urine or sweat testing if a metabolic amino acid disorder is suspected
- if distinctive fishy odor, consider trimethylaminuria, a rare inborn metabolism error; genetic testing confirms this diagnosis and the condition is managed with dietary modification
- PubMed27118741BMJ case reportsBMJ Case Rep201604262016review and case report of 9-year-old boy with trimethylaminuria can be found in BMJ Case Rep 2016 Apr 26;2016:
- PubMed29600922Nederlands tijdschrift voor geneeskundeNed Tijdschr Geneeskd20180101162D2068D2068review of trimethylaminuria can be found in Ned Tijdschr Geneeskd 2018;162:D2068 [Dutch]
- bacterial swabbing is not useful to guide management decisions, but could be considered for academic purposes
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483References - Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266
Management
- management decisions should be based on patient's quality of life and treatment expectations (Aust Fam Physician 2013 May;42(5):266)
- treat concomitant underlying skin or systemic conditions if present (Clin Dermatol 2015 Jul;33(4):483)
- conservative management may include
- regular cleansing of apocrine areas, for apocrine bromhidrosis
- axillary hair removal (reduces bacteria accumulation on hair shaft); however, consider other methods besides laser depilation as bromhidrosis has been reported as a side effect of laser hair removal
- antiperspirants/deodorants
- those containing aluminum salts are preferred, as these enhance drying, limit maceration, and are reported to potentially improve both types of bromhidrosis particularly when associated with hyperhidrosis
- antiperspirants may reduce sweat volume and if fragrant, may mask odor
- particular deodorants may contain specific antimicrobial metal ions or ceramics (such as zeolite or calcium phosphate) that inhibit axillary bacteria
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483References - Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266
- topical agents
- topical antiseptic agents advised as first choice to reduce risk of bacterial resistance to topical antibiotics
- topical antibacterial options may include clindamycin or erythromycin
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483References - Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266
- for patients refractory to conservative or topical treatment and who feel a significant impact on their activities of daily living due to bromhidrosis, reported options may include botulinum toxin-A (BTX-A) injection, surgery, or laser or microwave therapy (Clin Dermatol 2015 Jul;33(4):483, Aust Fam Physician 2013 May;42(5):266)
- botulinum toxin-A (BTX-A) injection
- botulinum toxin-A denervates eccrine sweat glands and temporarily decreases sweat production (Clin Dermatol 2015 Jul;33(4):483)
- STUDY SUMMARYbotulinum toxin-A may reduce odor and sweat production in adults with axillary bromhidrosisRANDOMIZED TRIAL: Dermatol Surg 2019 Dec;45(12):1605
- STUDY SUMMARYintradermal botulinum toxin A injection reported to resolve bromhidrotic malodor in 73% of patients for mean 4 months before recurrenceUNCONTROLLED TRIAL: J Dermatolog Treat 2012 Dec;23(6):461
- PubMed15355367Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]Dermatol Surg200409013091233-51233bromhidrosis of pubic region reported improved with BTX-A injection with persistent results for 9 months in 31-year-old woman in case report (Dermatol Surg 2004 Sep;30(9):1233)
- surgical approaches
- 3 options with reported success include removal of
- subcutaneous tissue without removing skin, and with or without axillary superficial fascia removal
- skin plus subcutaneous tissue en bloc
- skin plus subcutaneous tissue en bloc plus adjacent subcutaneous tissue
- regeneration of gland function may occur years after removal, depending on depth and extension of excision, thereby compromising long-term outcome
- other reported techniques include superficial liposuction curettage, characterized by suction removal of subcutaneous tissue through small axilla incisions, which may be a minimally invasive option allowing for outpatient treatment
- advantages may include smaller scars, lower complication rate, and minimal postoperative care
- may be associated with higher rate of recurrence than other surgical approaches
- reported novel approach includes combination surgical excision plus adjunctive carbon dioxide laser vaporization for residual apocrine glands
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483Reference - Clin Dermatol 2015 Jul;33(4):483
- STUDY SUMMARYsurgical apocrine gland clearance reported to reduce malodor but may be associated with skin scarring in adult with axillary bromhidrosisCASE SERIES: Int J Dermatol 2016 Aug;55(8):919
- small incisions in the axilla followed by scraping of subcutaneous apocrine glands reported to resolve bromhidrosis in 42 axillae in case series of 22 patients ( Medicine (Baltimore) 2019 May;98(22):e15865)
- 3 options with reported success include removal of
- laser therapy
- laser therapy with frequency-doubled, Q-switched Nd:YAG laser (1064 nm) has reported efficacy for long-term cure of axillary bromhidrosis
- laser may destroy apocrine glands by subdermal coagulation
- adverse effects may include transient pain and limited mobility for 1-4 weeks postoperatively
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483Reference - Clin Dermatol 2015 Jul;33(4):483
- STUDY SUMMARYlaser therapy reported to resolve bromhidrosis at 6 months in 55% of treated axillaeUNCONTROLLED TRIAL: Ann Dermatol 2014 Apr;26(2):184
- PubMed24648694Annals of dermatologyAnn Dermatol2014020126199-10299laser liposuction with 1,444 nm wavelength reported to have similar efficacy as conventional surgery in self-controlled case report of 25-year-old woman with bromhidrosis (Ann Dermatol 2014 Feb;26(1):99)
- PubMed31646163JAAD case reportsJAAD Case Rep20191007510915-9179152 sessions of microwave-based therapy (4 months apart) reported to improve bromhidrosis secondary to trimethylaminuria by 80%-85% in 31-year-old woman in case report (JAAD Case Rep 2019 Oct;5(10):915)
Chromhidrosis (colored sweat)
Chromhidrosis overview
- apocrine chromhidrosis is a rare disorder of colored apocrine sweat secretion, typically occurring around the axillary area or face and manifesting as stained clothing or undergarments
- sweat may be yellow, green, blue, brown, or black
- typical onset in puberty and generally continues with a chronic course but regresses with age due to age-related regression of apocrine glands
- reported to mainly occur on face, axillae, and breast areola
- etiology and predisposing factors are unknown, but pathophysiology is well-defined
- apocrine chromhidrosis occurs due to lipofuscin pigment granules (yellowish-brown pigment found in many cells) in apocrine glands occurring in either elevated concentrations or at higher-than-normal state of oxidation
- abnormal lipofuscin leads to blue, yellow, green, or black discoloration of apocrine secretions
- substance P (neurotransmitter and neuromodulator for pain perception and factor in apocrine sweat production) is hypothesized to be involved due to efficacy of capsaicin cream
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483Reference - Clin Dermatol 2015 Jul;33(4):483
Chromhidrosis presentation and diagnosis
- apocrine chromhidrosis typically presents as colored staining of clothes or underwear with sweating (often in axillary regions, less commonly areolar or facial staining)
- patients may report prodromal warming sensation or prickliness with physical or emotional stress prior to colored sweat appearing
- apocrine sweat characteristics
- odorless
- turbid
- variable color: may be yellow, green, blue, brown, or black with follicular accentuation (may be mechanically expressed from affected glands)
- when apocrine chromhidrotic sweat dries on the skin, it is lucent, adherent, and may look like colored scales
- 10% of general population reported to have colored sweat (physiologically normal) without chromhidrosis
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483Reference - Clin Dermatol 2015 Jul;33(4):483
- mimics include
- eccrine chromhidrosis, which results from ingestion of various dyes or drugs (for example, quinines
- pseudochromhidrosis, which occurs when compounds on the skin surface (such as extrinsic dyes, colorants, fungi, or chromogenic bacteria) mix with sweat and yield coloration on the skin surface
- PubMed28233291International journal of dermatologyInt J Dermatol20170501565496-502496noninfectious causes include clothing dye, chemical agents (such as self-tanner) and ingested medications such as lansoprazole and topiramate
- infectious pseudochromhidrosis occurs due to microorganism-produced pigments, which may be triggered by drugs or conditions that affect microflora composition of the skin; known culprits and resulting colors include
- Bacillus spp. - blue color
- Corynebacterium spp. - brown/black color
- Pseudomonas aeruginosa - green/blue color
- Serratia marcescens - red/pink color
- differential diagnosis of pseudochromhidrosis
- alcaptonuria, a rare inborn error of metabolism causing skin discoloration ranging from blue to yellow-brown
- hematidrosis, a rare disease of blood oozing from skin and mucosa
- PubMed31612235Acta dermato-venereologicaActa Derm Venereol202001071001adv00005adv00005References - Acta Derm Venereol 2020 Jan 7;100(1):adv00005, Int J Dermatol 2017 May;56(5):496, Clin Dermatol 2015 Jul;33(4):483
- diagnosis of chromhidrosis is clinical and testing is often unnecessary
- Wood lamp exam can confirm diagnosis with yellow fluorescence of the yellow, green, or blue apocrine secretions
- other tests that have been reported for diagnosis include
- stimulation of secretions with intradermal epinephrine or oxytocin
- standard ultraviolet microscopy of clothing can demonstrate yellow-green fluorescence of apocrine excretions that have adhered to clothing
- lab tests that may help differentiate chromhidrosis from exogenous coloration causes include
- urinary homogentisic acid levels to exclude alkaptonuria
- complete blood count to exclude bleeding diathesis
- appropriate fungal and bacteriologic culturing to exclude pseudochromhidrosis
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483Reference - Clin Dermatol 2015 Jul;33(4):483
- STUDY SUMMARYexogenous mineral exposure may be associated with chromhidrosisCOHORT STUDY: Pediatr Dermatol 2018 Jul;35(4):448
Chromhidrosis management and case reports
- management is symptomatic
- manual expression of affected glands reported to resolve symptoms for 48-72 hour periods, but chromhidrosis will recur
- capsaicin cream applied 1-2 times daily reported successful in case reports, but symptoms recur several days after discontinuation
- topical aluminum chloride antiperspirants may reduce sweating
- botulinum toxin-A (BTX-A) injection has been reported successful for facial and axillary chromhidrosis, with duration of effect of about 4-5 months (see also Botulinum toxin injections in Management of hyperhidrosis)
- age-related regression of apocrine glands may diminish symptoms
- PubMed26051066Clinics in dermatologyClin Dermatol20150701334483-91483Reference - Clin Dermatol 2015 Jul;33(4):483 and Australas J Dermatol 2016 Feb;57(1):e23
- case reports
- PubMed25753446The Australasian journal of dermatologyAustralas J Dermatol20160201571e23-5e23case report of blue-green chromhidrosis in 2 adolescent brothers with onset 2 years apart can be found in Australas J Dermatol 2016 Feb;57(1):e23
- PubMed25780968Dermatology online journalDermatol Online J20141214213case report of idiopathic red-hue chromhidrosis in 70-year-old man can be found in Dermatol Online J 2014 Dec 14;21(3):
- PubMed26632933Dermatology online journalDermatol Online J201511182111case report of blue-green eccrine chromhidrosis in middle-aged man due to ingestion of homeopathic medicine can be found in Dermatol Online J 2015 Nov 18;21(11):
- PubMed24026431JAMA dermatologyJAMA Dermatol20131101149111339-401339case report of acral green eccrine chromhidrosis in man in his 50s can be found in JAMA Dermatol 2013 Nov;149(11):1339
- PubMed25382536Indian journal of dermatology, venereology and leprologyIndian J Dermatol Venereol Leprol20141101806579579case report of late-onset apocrine chromhidrosis (blue-hue ) in 76-year-old man can be found in Indian J Dermatol Venereol Leprol 2014 Nov-Dec;80(6):579
Etiology and Pathogenesis
Causes
- primary hyperhidrosis etiology unclear, but may be associated with environmental and/or emotional triggers such as any of the following,
- anxiety or stress
- heat
- exercise
- tobacco
- alcohol
- hot spices
- secondary hyperhidrosis may be due to,,
- alcohol use disorder
- chronic pulmonary disease; acute respiratory failure
- congestive heart failure
- endocrine/metabolic disorders (such as diabetes mellitus, hyperthyroidism, hypothyroidism, hypoglycemia, hyperpituitarism, acromegaly)
- febrile illness/infection (such as defervescence, tuberculosis)
- malignancies (such as myeloproliferative disease, pheochromocytoma, carcinoid tumor, leukemia, lymphoma)
- medications, including
- antidepressants
- selective serotonin reuptake inhibitors
- serotonin-norepinephrine reuptake inhibitors
- cholinergic agonists (such as pilocarpine, pyridostigmine)
- hypoglycemics (including insulin, sulfonylureas, thiazolidinediones)
- selective estrogen receptor modulators (raloxifene, tamoxifen)
- others (infliximab, niacin, sildenafil)
- antidepressants
- neurologic conditions (such as Arnold-Chiari malformation, Parkinson disease, spinal cord injury, cerebrovascular accident)
- physiologic (such as menopause, pregnancy)
- psychiatric disease (such as generalized anxiety disorder, social anxiety disorder)
- opioid withdrawal
- substance use disorders; narcotic withdrawal
Pathogenesis
- most sweat glands are eccrine type in that they connect directly to skin, not to hair follicles (apocrine), and produce thin fluid that is hypotonic to plasma that is involved in thermoregulation
- sweat glands innervated by postganglionic autonomic nerve fibers and stimulated by acetylcholine, and involved in thermoregulation,
- increased or aberrant sympathetic stimulation of eccrine sweat glands may be responsible for increased sweating rather than an increased number or size of glands,
Images
All (5)Published by EBSCO Information Services. Copyright © 2025, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.
EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.
DynaMed Levels of Evidence
Quickly find and determine the quality of the evidence.
DynaMed provides easy-to-interpret Level of Evidence labels so users can quickly find and determine the quality of the best available evidence. Evidence may be labeled in one of three levels:
1Level 1 (likely reliable) Evidence
2Level 2 (mid-level) Evidence
3Level 3 (lacking direct) Evidence
Grades of Recommendation
Guideline producers are now frequently using classification approaches for their evidence and recommendations, and these classifications are recognized and requested by guideline users. When summarizing guideline recommendations for DynaMed users, the DynaMed Editors are using the guideline-specific classifications and providing guideline classification approach when this is done.
Download the full version of Levels of Evidence