Hyperhidrosis: Prevalence, Diagnosis, and Stepwise Treatment

Background: Hyperhidrosis, or sweating beyond the physiological amount, can be either focal or generalized and sometimes runs in families. The prevalence of primary idiopathic hyperhidrosis is 2–5%. Secondary hyperhidrosis is associated with specific illnesses and medications. In this article, we discuss the diagnostic evaluation of hyperhidrosis and treatments for it, along with their efficacy and side effects.

Methods: This narrative review is based on publications retrieved from the Medline and Cochrane databases with the search term “hyperhidrosis” and other specific terms relating to treatment. Expert recommendations and guidelines were considered as well.

Results: The diagnostic evaluation consists of a clinical history, a Minor (starch-iodine) test, gravimetry, and dynamic sudometry. There have been no more than a few high-quality published studies on specific interventions. Depending on the severity and symptom burden, aluminum chloride and anticholinergic drugs are used first, followed by botulinum toxin injections and subcutaneous curettage for axillary hyperhidrosis. These treatments reportedly bring about marked improvement in 60–70 % of patients; their side effects, depending on the particular treatment used, include local reactions such as itch, pain, and cutaneous irritation and anticholinergic effects such as dry mouth, mydriasis, urinary retention, and headache. Further therapeutic options are tap water iontophoresis; radiofrequency, focused ultrasound, and microwave treatment; systemically administered anticholinergic drugs; and thoracic or lumbar sympathectomy for palmar or plantar hyperhidrosis, respectively.

Conclusion: A variety of methods can be used to relieve hyperhidrosis and improve these patients’ quality of life. There have been no more than a few high-quality studies on their efficacy and long-term results.

Cite this as: Schreiner W, Rapprich S, Rzany B, Wiegering A: Hyperhidrosis: prevalence, diagnosis, and stepwise treatment. Dtsch Arztebl Int 2026; 123: 253–60. DOI: 10.3238/arztebl.m2025.0229

Hyperhidrosis (HH) is defined as excessive sweating that exceeds physiological levels and is classified into primary and secondary types (1). The prevalence of primary hyperhidrosis is 4.8% in the United States, 4.6% in Germany, and 5.5% in Sweden (2, 3); the combined prevalence of the two types is 16.3% in Germany and 20.3% in Sweden (2, 3). HH interferes with everyday life on the psychological, social, and occupational levels, and approximately half of those affected report an impaired quality of life (QOL) and express a need for treatment (2, 3, 4). Primary, idiopathic hyperhidrosis typically arises between the ages of 14 and 25, is focal in nature, and presents in various combinations of affected sites: 30–60% axillary, 10–40% each for palmar and plantar, and 10–20% faciocranial (2, 4, 5). Its etiology remains unclear. Familial clustering is present in 30–65% of cases (5, 6). Secondary hyperhidrosis is usually either craniofacial or generalized; its prevalence rises with age, especially after age 60. It is associated with other medical conditions and particular drugs (Box 1) (1, 2, 5). In this article, we describe the forms of hyperhidrosis, the necessary diagnostic procedures, and a stepwise approach to treatment.

Box 1

Causes of secondary hyperhidrosis*

Learning objectives

After reading this article, readers should be able to:

• distinguish the types of hyperhidrosis and know their characteristics with respect to prevalence and localization;
• carry out the indicated diagnostic evaluation in a targeted manner;
• describe a stepwise treatment approach for primary hyperhidrosis depending on its severity and localization and know the role of systemic anticholinergic drugs.

Methods

This narrative review is based on publications retrieved by a selective search in the Medline and Cochrane databases employing the terms “hyperhidrosis,” “topical treatment,” “tap water iontophoresis,” “anticholinergics,” “glucopyrronium,” “oxybutynin,” “vagantin,” “radiofrequency microneedling,” “microwave,” and “focused ultrasound.” Randomized controlled trials (RCTs) were included, as were prospective and retrospective studies. The studies were often small and frequently lacked an appropriate control group. The natural history of the disease, confounder effects, and biases all need to be taken into account (7). There have been no more than a few studies of its long-term outcome. Expert recommendations and available guidelines were also considered for this review (8, 9).

Diagnostic evaluation

A detailed medical history should be taken, including a detailed description of the patient’s symptoms, including the duration, frequency, and bodily sites of sweating and associated impairments, along with drugs taken, other medical conditions (Box 1), and a family history. The typical symptoms of primary/idiopathic focal hyperhidrosis are summarized in Box 2. Axillary and palmar-plantar hyperhidrosis can be classified semi-quantitatively by severity (Box 3) (9). Diagnostic methods for hyperhidrosis include photographic documentation (Figure 1), the Minor test, gravimetry, and/or dynamic sudometry. The Minor test, also called the iodine-starch test, mainly serves to visualize the condition; it is based on a chemical reaction between the sodium chloride contained in sweat and the iodine and starch applied topically to the skin (Figure 2). Gravimetry enables the quantification of hyperhidrosis through the absorption of sweat by filter paper over a defined period, followed by weighing in an ultra-precision balance. Because to individual variability as well as circadian and situational fluctuations, there are no generally accepted reference values, but values of >20 mg/min (palmar) and >50 mg/min (axillary) are considered pathological (6, 10). Dynamic sudometry involves sensor-based measurement of sweat production, either after stimulation or after treatment (10). Impairment in the quality of life can be assessed with hyperhidrosis-specific validated questionnaires such as the Dermatology Life Quality Index (DLQI) and the Hyperhidrosis Disease Severity Scale (HDSS) (Box 4) (11, 12).

Box 2

Typical symptoms of primary/idiopathic focal hyperhidrosis*

Box 3

Semi-quantitative severity classification of axillary (A) and palmoplantar (P) hyperhidrosis*

Box 4

Hyperhidrosis Disease Severity Scale (HDSS)

Figure 1

Photographic diagnosis of palmar hyperhidrosis: typical finding with widening of the print after ca. 5 minutes.

Figure 2

Diagnosis of palmar hyperhidrosis with the Minor test: typical finding with purple discoloration due to the starch-iodine reaction.

Stepwise treatment for primary hyperhidrosis

The need for treatment is determined by the severity of hyperhidrosis and the ensuing social, occupational, and functional limitations (DLQI, HDSS). Non-medical measures are recommended for initial treatment, including lifestyle changes such as weight loss, changes in the drug regimen if any, and avoidance of spicy food, alcohol, and coffee. As sweating in primary hyperhidrosis arises spontaneously and independently of physical activity, these measures are considered a useful adjunct. There are no uniform international guidelines for hyperhidrosis. A German-language S1 guideline for localized primary hyperhidrosis has been issued by the Association of Scientific Medical Societies in Germany (AWMF) (9). The recommended stepwise treatment involves conservative, invasive, and surgical measures; it is summarized here as a modified treatment algorithm with consideration of both the severity and the location of excessive sweating (Box 5). In secondary hyperhidrosis, treatment is centered on the underlying cause along with symptomatic treatment of excessive sweating.

Box 5

Stepwise treatment for various forms of hyperhidrosis*1

Topical treatment

The first line of medical treatment is with topical antiperspirant preparations—aluminum chloride (AlCh) or anticholinergics—which should be applied in the evening, so that they can be absorbed transdermally overnight and take effect during the day.

The first step is usually the topical application of AlCh, which is available in concentrations ranging from 10% to 30%. AlCh binds chemically with mucopolysaccharides, leading to closure of the excretory ducts of the eccrine sweat glands and thereby reducing sweating. A discussion arose a few years ago about its potential carcinogenicity. On the basis of current scientific knowledge, the German Federal Office for Risk Assessment classifies the cancer risk associated with its regular use as very low (13).

In a retrospective, uncontrolled study, 336 of 691 patients treated with aluminum chloride for axillary hyperhidrosis were followed for five months. 82% were satisfied with the results. Of the three concentrations used, the 15% concentration was rated most favorably. Pruritus occurred initially in two patients and skin irritation in one-third; after six months, these symptoms persisted in half and one-sixth of the subjects, respectively. Among the patients who experienced these symptoms, pruritus was severe in 9% and moderate in 21%, an skin irritation was severe in 14% and moderate in 36% (14).

In a randomized, controlled trial (RCT) with 80 subjects, topical 20% AlCh was compare to oral oxybutynin hydrochloride (an anticholinergic drug) for the treatment of primary palmar hyperhidrosis. After 12 weeks of treatment, sweating improved by two HDSS points (an approximately 80% reduction in sweating) in 65% and 15% of those treated, respectively, and by one or zero HDSS points in the remainder (p ≤ 0.001). One week after the end of treatment, sweating had returned to its previous level. Side effects under AlCh included itching (65%), burning (57%), and skin irritation (33%); under oxybutynin, dry mouth (66%), nausea (28%), and headache (20%) (15).

For axillary hyperhidrosis, anticholinergic substances are also used topically, such as glycopyrronium (GP) tosylate and bromide in the form of impregnated wipes or oxybutynin chloride, a muscarinic receptor antagonist, as a 1%, 3%, or 10% gel. After transdermal diffusion, they bind to the acetylcholine receptor in the neuromuscular synapse, thereby preventing the activation of the eccrine sweat gland (16). In two randomized, double-blind phase III studies, ATMOS 1 (n = 344) and ATMOS 2 (n = 353), axillary sweating improved by at least 4 points (Item 2 of the “axillary sweating daily diary” scale, 0–10 points, co-primary outcome) in 59% of those treated, compared to 26% of the placebo group (p < 0.001). The improvements were similar for the remaining items and comparable across children, adolescents, and adults (17, 18). Adverse side effects were somewhat common with the active agent than with placebo: dry mouth (24% versus 6%), local skin reactions (30% each), accommodation disturbance (3.5% versus 0%), mydriasis (7% versus 0%), headache (5% versus 2.2%), and urinary retention (1.5% versus 0%) (17). Once-daily application, thorough hand washing after application, and avoidance of eye contact are recommended to lessen or prevent side effects. No comparative study with the AlCh-containing topical preparation is available.

In one study (n = 61, intra-individual randomization), blinded dermatologists found that hyperhidrosis was markedly improved after four weeks of palmar, axillary, or plantar application of a 10% oxybutynin chloride gel, compared to the placebo-treated side. An improvement by one point on the HDSS scale was reported by 75% of subjects treated for axillary hyperhidrosis and by 65% and 50% of those treated for palmar and plantar hyperhidrosis, and 5–10% reported an improvement by two points. Local redness or itching arose in eleven cases, and transient headache in two (19). In another RCT with 40 subjects, there was a more pronounced improvement in the HDSS score (from 3.7 to 0.9) after four weeks of blinded application of 3% oxybutynin chloride gel for palmar, plantar, and axillary hyperhidrosis compared to 15% AlCh lotion (3.9 to 2.3); the difference was no longer present at 1 month (20).

Tap water iontophoresis

Tap water iontophoresis (TWI) is used in particular to treat palmar-plantar hyperhidrosis. A continuous or pulsed current is applied to the skin with cutaneous electrodes. The mechanism of action has not been clearly established but is assumed to involve reversible disruption of ion transport in the secretory complex of the sweat glands, possibly by an accumulation of H+ ions in the sweat gland ducts (6). The treatment is frequently administered at home by the patients themselves. Pain, paresthesia, intermittent redness, and blistering have been described as adverse effects. Contraindications include an implanted pacemaker, other metal implants, pregnancy, and open wounds. In an RCT that included 29 patients with palmar hyperhidrosis, the symptoms improved by at least 1 HDSS point after two weeks of treatment in 79% of the treated patients and 31% of those in the sham-treatment group, and gravimetrically confirmed sweat reduction was found in 92% and 39%, respectively. 72% of those treated reported symptom improvement that was still evident four weeks after the end of treatment (21). In general, the effect of TWI persists for 4–12 weeks, so its continuation as maintenance therapy is recommended at intervals no longer than 1 to 4 weeks (21).

Locally invasive treatments

Botulinum toxin

Botulinum toxin reversibly blocks acetylcholine receptors at the neuromuscular synapse. In Germany, botulinum toxin A is approved exclusively for the treatment of severe primary axillary hyperhidrosis when topical treatment has been found ineffective; application at other sites is off label. In Austria, Dysport (abobotulinum toxin A) is also approved for the treatment of axillary hyperhidrosis, in addition to botulinum toxin. The drug is introduced subcutaneously at individual injection points; the spacing between them depends on the dose at each. In the axillary region, they are spaced ca. 1 cm apart, and most patients do not need a local anesthetic. For injections in the hands and feet, a topical local anesthetic may be applied beforehand. In a before-and-after study with 91 patients, botulinum toxin treatment for axillary hyperhidrosis led to improvements in the mean HDSS score from 3.4 to 1.5 (p < 0.001) and in the DLQI from 19 to 6.9 (p < 0.001) one year after treatment, showing that botulinum toxin can bring about long-term improvement (22). In a retrospective study of 30 patients who had been treated with BT for palmar hyperhidrosis, 28 (93%) experienced improvement of the HDSS score by at least one point. After the first treatment, the improvement lasted for a median of 4 months (1–14 months). In one case, compensatory axillary sweating arose. In seven study participants (23 %), there was a transient reduction in grip strength for 2 weeks. In a further case, the hand muscles were weakened to the extent that the patient could no longer unscrew a bottle cap (23). In the ideal case, botulinum toxin injections are needed only once or twice a year. While no more than mild to moderate adverse effects are expected in the axillary region, palmar application can cause local pain, pruritus, and hand muscle weakness (22, 23).

Radiofrequenz, fokussierter Ultraschall und Mikrowellen-Therapie

These alternative procedures are used exclusively to treat axillary hyperhidrosis. All three induce thermal damage to the sweat glands by application of heat at the transition zone between the subcutis and the epidermis. The heat application is not selective and can damage other structures as well. The efficacy of these procedures has not yet been adequately studied (9).

Radiofrequency treatment

In radiofrequency treatment, thermal energy is applied in a targeted manner via subcutaneously inserted microneedles (so-called radiofrequency microneedling), thereby inducing a remodeling process that involves keratinocyte and fibroblast migration (24). Multiple sessions may be needed to achieve the desired reduction of sweating. The therapeutic effect of three radiofrequency sessions spaced three weeks apart was studied in 25 patients with an intra-individual comparison of the radiofrequency-treated and untreated axillae. In addition to photographic documentation, symptoms were assessed with the HDSS for three months, and also one year after the last session. In the first three months, the HDSS improved from 3.38 to 1.87 after radiofrequency treatment, and skin biopsies yielded histological evidence of a reduction in the number of sweat glands (25). The improvement was sustained at one year, with an HDSS score of 2.5 compared to 3.38 on the untreated side (p < 0.001) (26).

Focused ultrasound

Focused ultrasound destroys tissue with heat arising from induced vibration. In a before-and-after study involving 16 patients, there was 50% less sweating at three months; in an RCT involving 20 patients, the HDSS score fell by at least one point in 67% of patients, indicating an improvement in the quality of life. All of the treated patients experienced mild adverse effects, mostly local reactions (27).

Microwaves (MiraDry)

Microwaves delivered transcutaneously with a device made for this purpose cause irreversible thermolysis owing to the higher water content in the dermis and sweat glands than in the subcutis. In a before-and-after study in 31 patients treated with microwaves for axillary hyperhidrosis, 94% had an improvement by at least 1 HDSS point and 55% by at least 2 HDSS points 12 months after the end of treatment. Gravimetrically measured sweat production was reduced by half in 90% (28). Redness, swelling, and sensory disturbances were transient side effects. Neuropathic symptoms and arm weakness lasting several months were observed in rare cases (28, 29).

Surgical techniques

Surgery is the last resort when all options for conservative treatment and nonsurgical intervention have been exhausted. It involves either the removal of sweat glands to treat axillary hyperhidrosis or the interruption of nerve transmission in the thoracic and lumbar sympathetic nervous system to treat palmar and plantar hyperhidrosis.

Radical excision

In radical excision, the sweat-gland-bearing axillary skin is extensively resected, and a reconstruction follows, with an expansion, rotation, or transposition plasty (e.g., the Shelley technique or Salfeld procedure) (30). These techniques are rarely used today because they can result in troublesome hypertrophic or hypotrophic scarring and contractures (8).

Subcutaneous (suction) curettage

Subcutaneous curettage is performed with a ring curette at the lower edge of the dermis through multiple small incisions under local, tumescent, or general anesthesia. During the procedure, the skin area is extensively undermined and detached. Scarring is much less than after radical excision, but skin necrosis, hematomas, lymphatic fistulae, and seromas can arise. In a retrospective study, the recovery time was shorter after curettage (1.3 days, 39 patients)than after excision (8.8 days, 99 patients), and a pain-free state was also more common afterward (89% vs. 24%). Hyperhidrosis recurred within 1 year of treatment in 16% of patients who had undergone curettage and in 1% who had undergone after excision (31). A randomized, controlled trial (n = 20, intra-individual randomization) showed that the reduction of sweating three months after axillary sweat gland curettage was comparably that after botulinum toxin injection (72% versus 60% at rest). With botulinum toxin, the quality of life was better, and, in cases of severe hyperhidrosis, the exercise-induced sweat production was lower (32). In view of its efficacy and rare adverse effects, suction curettage of the sweat glands is preferable to radical excision.

Surgery on the thoracic sympathetic nervous system

Among the surgical techniques directed at the thoracic sympathetic nervous system, sympathectomy, sympathotomy, and clip application are the best established (33). Sympathectomy involves a partial resection of the sympathetic chain, typically at levels from the second to the fifth rib. Sympathotomy involves transection of the sympathetic chain with scissors, electrocoagulation, or a laser. In clip application, also known as endoscopic sympathetic block, the sympathetic chain is selectively blocked at the appropriate ganglionic level corresponding to the site of sweating.

All of these methods interrupt sympathetic nerve impulse transmission in order to achieve, ideally, complete dryness in the target area, starting immediately after the procedure. The extent of collateralization varies across individuals, however, and hyperhidrosis may therefore recur postoperatively, usually after a latency of several weeks and less severely than before. Patients under age 25 who have no comorbidities or bradycardia, a body mass index (BMI) under 28, and no sweating at night are good candidates for sympathetic nerve surgery (33).

Compensatory sweating develops postoperatively in a different anatomical region of the body than the initial hyperhidrosis. In a retrospective cohort study, moderate and marked improvement in the quality of life was obtained after sympathectomy by 76% and 9% of 2,431 patients who had mainly suffered from palmar and axillary hyperhidrosis. Compensatory sweating arose in 90% of those treated and was severe in 22% (34). In a retrospective study from Germany, compensatory sweating arose in 76%, and severe compensatory sweating in 19%, of 105 patients with craniofacial, axillary, palmar, and plantar hyperhidrosis who had undergone endoscopic sympathetic nerve block (35). Horner’s syndrome was observed in 0.7–3% of cases (33). In rare cases, intermittent asystole or marked bradycardia occurred intraoperatively, occasionally necessitating pacemaker implantation (33, 36).

Surgery on the lumbar sympathetic nervous system

Laparoscopic lumbar sympathectomy or sympathetic ganglionectomy can be used to treat plantar hyperhidrosis. In a before-and-after study, plantar sweating was reduced in all treated patients, although 47% had previously undergone sympathectomy for initially combined palmoplantar hyperhidrosis (37). Ejaculatory dysfunction and impotence are potential adverse effects arising mainly after procedures in the L2 region. It is therefore recommended that this procedure should only be performed below L3, especially in men (37).

Systemic Treatment

Systemic treatment is primarily used to treat generalized hyperhidrosis or, in certain situations, focal hyperhidrosis. Aside from over-the-counter remedies such as sage tablets, the medications used are anticholinergic drugs (muscarinic receptor antagonists) such as methantheline bromide and oxybutynin hydrochloride.

Methantheline bromide specifically blocks the neural activation of the sweat glands and is mainly used to treat focal, especially axillary hyperhidrosis. Its effect lasts six hours after the oral administration of 50–100 mg, so multiple doses per day are required (38). A placebo-controlled RCT (n = 41) demonstrated a gravimetric reduction in axillary sweat production (89.2 to 53.3 mg/min, p = 0.02), but not in palmar sweat production (38) . Dry mouth was the most common adverse effect, arising in 47% of treated patients versus 11% of controls, usually in the first two weeks of treatment.

Oxybutynin hydrochloride is rapidly absorbed and attains its maximum concentration within one hour of oral administration, while its half-life is two to three hours (39). In an RCT involving 62 patients, most of whom had generalized hyperhidrosis, 60% of those treated with oxybutynin reported a decrease in the HDSS score by at least 1 point, compared to 27% of the control patients (p = 0.009); oxybutynin also improved the quality of life (DLQI) (40). Dry mouth was the most common adverse effect of oral oxybutynin administration (43% versus 11%) but was only mild or moderate in 84% of the patients who suffered from it (40).

The use of anticholinergic drugs should be guided by the relative efficacies of all available treatment options for the form of hyperhidrosis affecting the individual patient. These drugs are thus recommended as third-line treatment for axillary and palmar hyperhidrosis and as first-line treatment for craniofacial and generalized hyperhidrosis (8, 40).

Conflict of interest statement
SR received payment in connection with the GPBK study. The other authors state that they have no conflict of interest.

Manuscript received on 3 March 2025 and accepted after revision on 28 November 2025.

Translated from the original German by Ethan Taub, M.D.

Corresponding author
Prof. Dr. med. Waldemar Schreiner

References

1. Woerle B, Rapprich S, Heckmann M: Definition and treatment of primary hyperhidrosis. J Dtsch Dermatol Ges 2007; 5: 625–8

2. Doolittle J, Walker P, Mills T, Thurston J: Hyperhidrosis: An update on prevalence and severity in the United States. Arch Dermatol Res 2016; 308: 743–9

3. Shayesteh A, Janlert U, Brulin C, Boman J, Nylander E: Prevalence and characteristics of hyperhidrosis in Sweden: A cross-sectional study in the general population. Dermatology 2016; 232: 586–91

4. Henning MAS, Barati F, Jemec GBE: Quality of life in individuals with primary hyperhidrosis: A systematic review and meta-analysis. Clin Auton Res 2023; 33: 519–28

5. Kisielnicka A, Szczerkowska-Dobosz A, Purzycka-Bohdan D, Nowicki RJ: Hyperhidrosis: Disease aetiology, classification and management in the light of modern treatment modalities. Postepy Dermatol Alergol 2022; 39: 251–7

6. Schlereth T, Dieterich M, Birklein F: Hyperhidrosis—cases and treatment of enhanced sweating. Dtsch Aerztbl Int 2009; 106: 32–7

7. Kristensen JK, Nielsen C: Progress and lack of progress in hyperhidrosis research 2015–2020. A concise systematic review. Int J Dermatol 2022; 61: 148–57

8. Solish N, Bertucci V, Dansereau A, et al.: A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: Recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg 2007; 33: 908–23

9. Rzany B, Bechara F, Feise K, et al.: S1-Leitlinie Definition und Therapie der primären Hyperhidrose. AWMF-Register-Nr.: 013–059, 2023 www.register.awmf.org/de/leitlinien/detail/013–059.

10. Schick C: Pathophysiology of hyperhidrosis. Thorac Surg Clin 2016; 26: 389–99

11. Finlay AY, Khan GK: Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol 1994; 19: 210–6

12. Kamudoni P, Mueller B, Salek MS: The development and validation of a disease-specific quality of life measure in hyperhidrosis: The Hyperhidrosis Quality of Life Index (HidroQOL). Qual Life Res 2015; 24: 1017–27

13. Bundesinstitut für Risikobewertung: Neue Studien zu aluminiumhaltigen Antitranspirantien: Gesundheitliche Beeinträchtigungen durch Aluminium-Aufnahme über die Haut sind unwahrscheinlich. www.bfr.bund.de/cm/343/neue-studien-zu-aluminiumhaltigen-antitranspirantien-gesundheitliche-beeinträchtigungen-durch-aluminium-aufnahme-ueber-die-haut-sind-unwahrscheinlich.pdf (last accessed on 27 September 2025).

14. Hoelzle E: Topical pharmacological treatment. Curr Probl Dermatol 2002; 30: 30–43

15. Attallah HS, El-Gilany AH, Youssef YEB, Abdelshaheed ME, Sharaf EFA: Efficacy, safety and quality of life of oxybutynin versus aluminum chloride hexahydrate in treating primary palmar hyperhidrosis. Indian J Dermatol 2022; 67: 222–7

16. Lamb Y: Topical glocopyrronium tosylate in primary axillary hyperhidrosi: A profile of its use. Clin Drug Investing 2019; 39: 1141–7

17. Glaser DA, Hebert AA, Nast A, et al.: Topical glycopyrronium tosylate for the treatment of primary axillaryhyperhidrosis: Results from the ATMOS-1 and ATMOS-2 phase 3 randomized controlled trials. J Am Acad Dermatol 2019; 80: 128–38

18. Herbert AA, Glaser DA, Green L, et al.: Glycopyrronium tosylate in pediatric primary axillary hyperhidrosis: Post hoc analysis of efficacy and safety findings by age from two phase three randomized controlled trials. Pediatric Dermatology 2019; 36: 89–9

19. Artzi O, Loizides C, Zur E, Sprecher E: Topical oxybutynin 10 % gel for the treatment of primary focal hyperhidrosis: A randomized double-blind placebo-controlled split area study. Acta Term Venereol 2017; 97: 1120–4

20. El-Samadony AE, Hegab DS, El Maghraby GM, El-Maadawy IH: Topical oxybutynin 3 % gel versus aluminum chloride 15 % lotion in treatment of primary focal hyperhidrosis. Dermatol Pract Concept 2023; 13: e2023192

21. Kim DH, Kim TH, Lee SH, Lee AY: Treatment of palmar hyperhidrosis with tap water Iontophoresis: A randomized, sham-controlled, single-blind, and parallel-designed clinical trial. Ann Dermatol 2017; 29: 728–34

22. Castiglione L, Murariu M, Boeriu E, Enatescu I: Assessing botulinum toxin effectiveness and quality of life in axillary hyperhidrosis: A one-year prospective study. Diseases 2024; 12: 15

23. Farrell J, Stewart T, Singh B, Singh G, Rosen R: Retrospective analysis of the efficacy and duration of botulinum toxin A injections in 30 patients with palmar hyperhidrosis. Intern Med J 2021; 51: 1517–21

24. Hashimoto FN, Cataneo DC, Hashimoto EN, Ximenez AMG, Cataneo AJM: Radiofrequency in the treatment of primary hyperhidrosis: Systematic review and meta-analysis. Clin Auton Res 2020; 30: 11–120

25. Naeini FF, Abtahi-Naeini B, Pourazizi M, et al.: Fractionated microneedle radiofrequency for treatment of primary axillary hyperhidrosis: A sham control study: Radiofrequency for treatment of PAH. Australas J Dermatol 2015; 56: 279–84

26. Abtahi-Naeini B, Naeini FF, Saffaei A, et al.: Treatment of primary axillary hyperhidrosis by fractional microneedle radiofrequency: Is it still effective after long-term follow-up? Indian J Dermatol 2016; 61: 234

27. Nestor MS, Park H: Safety and efficacy of micro-focused ultrasound plus visualization for the treatment of axillary hyperhidrosis. J Clin Aesthet Dermatol 2014; 7: 14–21

28. Hong HC, Lupin M, O`Shaughnessy KF: Clinical evaluation of a microwave device for treating axillary hyperhidrosis. Dermatol Surg 2012; 38: 728–35

29. Suh Dh, Lee SJ, Kim K, Ryu HJ: Transient median and ulnar neuropathy associated with a microwave device for treating axillary hyperhidrosis. Dermatol Surg 2014; 40: 482–5

30. Bechara FG: Hyperhidrosis—causes and treatment of enhanced sweating: Surgical treatment of focal hyperhidrosis. Dtsch Arztebl Int 2009; 106: 448

31. Wollina U, Köstler E, Schrönlebe J, et al.: Tumescent suction curettage versus minimal skin resection with subcutaneous curettage of sweat glands in axillary hyperhidrosis. Dermatol Surg 2008; 34: 709–16

32. Ibrahim O, Kakar R, Bolotin D, et al.: The comparative effectiveness of suction-curettage and hnabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: A randomized control trial. J Am Acad Dermatol 2013; 69: 88–95

33. Cerfolio RJ, De Campos JR, Bryant AS, et al.: The society of thoracic surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011; 91: 1642–8

34. Wolosker N, de Campos JRM, Kauffman P, et al.: Cohort study on 20 years‘ experience of bilateral video-assisted thoracic sympathectomy (VATS) for treatment of hyperhidrosis in 2431 patients. Sao Paulo Med J 2022; 140: 284–9

35. Schreiner W, Mykoliuk I, Dudek W, Sirbu H: Bedeutung der selektiven Lebensqualitätsanalyse nach Sympathikus-Clipping bei Patienten mit lokaler Hyperhidrose. Zentralbl Chir 2019; 144: 139–45

36. O`Connor K, Molin F, Poirer P, Vaillancourt R: Cardiac arrest as a major complication of bilateral cervico-dorsal sympathectomy. Interact Cardiovasc Thorac Surg 2009; 8: 238–9

37. Hur KJ, Moon HW, Park YH, et al.: Retroperitoneoscopic lumbal sympathectomy for the treatment of primary plantar hyperhidrosis. BMC Surg 2021; 21: 397

38. Hund M, Sinkgraven R, Rzany B: Randomisierte, plazebo-kontrollierte Doppelblindstudie zur Wirksamkeitsbewertung und Sicherheit von Methantheliniumbromide (Vagantin) zur Behandlung der fokalen Hyperhidrose. J Dtsch Dermatol Ges 2004; 2: 343–49

39. Campanati A, Gregoriou S, Kontochristopoulos G, Offidani A: Oxybutynin for treatment of primary hyperhidrosis: urrent state of the art. Skin Appendage Disord 2015; 1: 6–13

40. Schollhammer M, Brenaut E, Menard-Andivot N, et al.: Oxybutynin as a treatment for generalized hyperhidrosis: A randomized, placebo-controlled trial. Br J Dermatol 2015; 173: 1163–8

e1. McConaghy JR, Fosselman D: Hyperhidrosis: Management options. Am Fam Physician 2018; 97: 729–34