Should Children and Adolescents Be Screened for Primary Hyperhidrosis?

Primary hyperhidrosis (PH) is a chronic, often underreported and underdiagnosed condition without a cure. While it frequently runs in families, the exact etiology is unknown.^1-5 Treatment focuses on symptom management and reducing the impact of excessive sweating on quality of life.^1,5 Some organizations recognize hyperhidrosis as a disability.^6,7 Symptoms typically begin in childhood or adolescence, particularly around puberty,^4,8 but treatment may not be initiated until late adolescence or early adulthood.^4,9

Patients with PH symptoms may suffer in silence and parents and caregivers may not recognize that excessive sweating is a medical condition warranting treatment.¹ Patients with PH may present dermatologists with other skin conditions such as acne, eczema or bacterial or fungal infections of the skin; such conditions are often exacerbated by excessive sweating.^10,11 As PH can be episodic and unpredictable, visible sweating during an office visit may be absent. Therefore, routine PH screening using validated screening tools along with medical history and the “ABCs” is paramount to appropriate identification and diagnosis.^2,12,13

PATIENT IDENTIFICATION

A survey of 539 children and adolescents aged 6 to 18 years with primary focal hyperhidrosis symptoms found that while 91% of participants consulted a health care professional about their excessive sweating, only 42% received a diagnosis.⁴ Among those who saw a dermatologist, pediatrician, or family practitioner, nearly half reported the discussion ended with their excess sweating being considered normal or with a plan to follow up at a future visit.⁴ Screening is a crucial first step in identifying individuals who may have PH.^2,13 This process helps clinicians determine whether a more in-depth assessment is needed.

Identification of primary hyperhidrosis is vital because it can:

• Foster appropriate treatment strategies to reduce excessive sweating. Among the 91% of 6–18-year-old survey participants who consulted with a healthcare provider about PH symptoms, prescription medications and procedures were infrequently discussed or used.⁴
• Improve patient quality of life. Children and adolescents with PH report higher levels of anxiety, depression and self-esteem issues. ^4,8,14-16
• Reduce potential exacerbation of atopy, psoriasis, hidradenitis suppurativa (HS), skin barrier dysfunction, and fungal and/or bacterial infections that result from moisture retention and microbial overgrowth.^10,11

SCREENING TOOLS

Hyperhidrosis Disease Severity Scale (HDSS) is a validated 4-point scale used assess PH severity and can be administered by an interviewer or self-completed by the patient. The HDSS is scored as follows:^17,18

• 1 point for sweating that is not noticeable and does not interfere with daily activities;
• 2 points for sweating that is tolerable but sometimes interferes with daily activities;
• 3 points for sweating that is barely tolerable and often interferes with daily activities;
• 4 points for intolerable sweating that always interferes with daily activities

A score of 2 is considered mild, with a score of 3 or 4 is considered severe. This tool is not specific to axillary hyperhidrosis.

The Hyperhidrosis Disease Severity Measure–Axillary 11 (HDSM-Ax-11) is a fit-for-purpose outcome measure with 11 items designed to measure PAH severity. Accurate and comprehensive, its development satisfies scientific and regulatory requirements for determining efficacy in PAH treatment clinical trials and may be administered by an interviewer or self-completed by the patient. Similarly, the HDSM-Ax-7 screening tool, a shorter version with only 7 items, is also available.^19-21

THE ABCS¹³

A: Age of onset – PH usually begins during childhood or adolescence.

Ask: When did your patient begin to experience excessive, uncontrollable sweating?

B: Bilateral – PH presents bilaterally, with symmetric, focal involvement of palms, feet, face/scalp and/or axillae.

Ask: Do you have excessive sweating on both sides of your body?

C: Cessation during sleep – In PH, excessive sweating ceases during sleep.

Ask: Does excessive sweating stop while sleeping?

D: Duration – PH is characterized by 2 or more excessive sweating episodes per week over at least 6 months.

Ask: How long have you experienced excessive sweating? How many times per week have you experienced excessive sweating?

E: Episodes – In PH, excessive sweating episodes will vary in frequency, length and severity.

Ask: How many episodes of excessive sweating do you have per week?

F: Family – PH tends to run in families but may not be outwardly discussed due to embarrassment. 

Ask: Do you have one or more blood relative who have/had excessive sweating episodes?

G: Gets in the way – PH may interfere with activities of daily living, including school, athletics, work and leisure activities.

Ask: How does excessive sweating affect your daily life, health and self-concept? 

WHO SHOULD BE SCREENED?

• Prepubescent and pubescent children, teens and young adults
• Individuals experiencing visible, bilateral and excessive sweating in one or more body areas (hands, feet, underarms)
• Sweating that interferes with daily activities
• Excessive sweating that has lasted at least 6 months
• People with a family history of excessive sweating 

THE SCREENING PROCESS

1. Choose a validated screening tool appropriate for the patient population and setting.

2. Administer the tool according to guidelines.

3. Interpret the results to determine severity and affected body areas

4. Refer the patient to a dermatology professional for comprehensive evaluation and treatment.

Given that PH is underreported and underdiagnosed, routine screening in children and adolescents using validated tools such as the HDSS and the ABCs is recommended. Early recognition of PH in symptomatic individuals may improve treatment outcomes and mitigate associated anxiety and depression.²²

The authors report no relevant financial disclosures.

1. Gorelick J, Friedman A. Diagnosis and management of primary hyperhidrosis: practical guidance and current therapy update. J Drugs Dermatol. 2020;19(7):704-710.
2. Owen K. Excessive sweating: are patients suffering unnecessarily? J Nurse Pract. 2016;12(1):35-40.
3. Wadhawa S, Agrawal S, Chaudhary M, Sharma S. Hyperhidrosis prevalence: a disease underreported by patients and underdiagnosed by physicians. Indian Dermatol Online J. 2019;10(6):676-681.
4. Rice Z, Sidbury R, Pieretti L, et al. Hyperhidrosis affects multiple focal areas and is undertreated in pediatric sufferers: survey results from population of >500 children and adolescents (ages 6-18). Presented at: 19th Annual South Beach Symposium; February 4–7, 2021.
5. Brackenrich J, Medeus CF. Hyperhidrosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Updated October 3, 2022. Accessed October 20, 2025. https://www.ncbi.nlm.nih.gov/books/NBK459227/
6. Hyperhidrosis veteran's benefits. DisabledVets.com. Accessed July 11, 2025. https://www.disabledvets.com/claim-types/physical-conditions/hyperhidrosis
7. International Hyperhidrosis Society. Paving a way for hyperhidrosis accommodations in the workplace. Published 2017. Accessed July 10, 2025. https://www.sweathelp.org/hh-awareness-month/ihhs-at-t-partnership.html
8. Nastase F, Verenca MC, Niculet E, et al. Primary hyperhidrosis in children—a retrospective study and a short review. Life (Basel). 2024;14(5):645. doi:10.3390/life14050645
9. Shayesteh A, Gerdsdorff F, Persson M, Brulin C, Nylander E. Navigating in the fog: facing delays, rejection and ignorance when seeking help for primary hyperhidrosis. Int J Qual Stud Health Well-being. 2021;16(1):1930642. doi:10.1080/17482631.2021.1930642
10. Maazi M, Leung AK, Lam JM. Primary hyperhidrosis: an updated review. Drugs Context. 2025;14:2025-3-2. doi:10.7573/dic.2025-3-2
11. Hua VJ, Kuo KY, Cho HG, et al. Hyperhidrosis affects quality of life in hidradenitis suppurativa: a prospective analysis. J Am Acad Dermatol. 2020;82(3):753-754. doi:10.1016/j.jaad.2019.10.024
12. Doolittle J, Walker P, Mills T, Thurston J. Hyperhidrosis: an update on prevalence and severity in the United States. Arch Dermatol Res. 2016;308(10):743-749. doi:10.1007/s00403-016-1697-9
13. International Hyperhidrosis Society. ABCs of hyperhidrosis diagnosis. Accessed September 10, 2025. https://www.sweathelp.org/about-hyperhidrosis/diagnosisguidelines.html
14. Kamudoni P, et al. The impact of hyperhidrosis on patients' daily life and quality of life: a qualitative investigation. Health Qual Life Outcomes. 2017;15:121. doi:10.1186/s12955-017-0693-x
15. Parashar K, Adlam T, Potts G. The impact of hyperhidrosis on quality of life: a review of the literature. Am J Clin Dermatol. 2023;24(2):187-198.
16. Glaser DA, et al. Understanding patient experience with hyperhidrosis: a national survey of 1,985 patients. J Drugs Dermatol. 2018;17(4):392-396.
17. McConaghy JR, Fosselman D. Hyperhidrosis: management options. Am Fam Physician. 2018;97(11):729-734.
18. Kowlaski J, Eadie N, Dagget S, Lai-PY. Validity and reliability of the hyperhidrosis disease severity scale (HDSS). J Am Acad Dermatol. 2004;50(3)(suppl):P51.
19. Kirsch BM, Burke L, Hobart J, Angulo D, Walker PS. The Hyperhidrosis Disease Severity Measure-Axillary: conceptualization and development of item content. J Drugs Dermatol. 2018;17(7):707-714.
20. Hobart J, Burke L, Kirsch B, Chadha D. Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax): evaluation of measurement performance. J Drugs Dermatol. 2021;20(4):410-418.
21. Pariser D, Glaser DA, Del Rosso J, et al. Sofpironium topical gel, 12.45%, for the treatment of axillary hyperhidrosis: pooled efficacy and safety results from 2 phase 3 randomized, controlled, double-blind studies. J Am Acad Dermatol. 2025;93(1):82-88. doi:10.1016/j.jaad.2025.04.013
22. Weber A, Heger S, Sinkgraven R, et al. Psychosocial aspects of patients with focal hyperhidrosis: marked reduction of social phobia, anxiety and depression and increased quality of life after treatment with botulinum toxin A. Br J Dermatol. 2005;152(2):342-345.