Search the Health Library
Get the facts on diseases, conditions, tests and procedures.
I Want To...
I Want To...
Find Research Faculty
Enter the last name, specialty or keyword for your search below.
School of Medicine
Through the online educational seminar, “Do You Suffer from Excessive Sweating,” Dr. Malcolm Brock helps people better understand excessive sweating (hyperhidrosis). These are answers to some of the most commonly asked questions. View the entire seminar here.
- What is hyperhidrosis?
- What causes hyperhidrosis?
- Where on the body do people experience excess sweating?
- Is there any way I might outgrow hyperhidrosis?
- How do you diagnose hyperhidrosis?
- What are the treatments for hyperhidrosis?
- What should I expect during the procedure?
- What are the surgical treatments for hyperhidrosis?
- What should I expect from the surgery?
- What are patients’ levels of satisfaction after surgery?
- What is compensatory sweating?
- Is there a way to reverse the surgery?
- Does insurance cover this procedure?
Hyperhidrosis is excessive sweating. Hyper means “more” and hidrosis means “sweating.” The body uses sweat to regulate temperature and sweat is one way the body cools. When people sweat too much, however, it could mean they have this condition.
Hyperhidrosis can be a socially isolating condition, as their excessive sweat can be embarrassing. This condition affects 3% of the population.
When people have hyperhidrosis, they have the normal amount of sweat glands but their sympathetic response is higher. This means that when they begin to sweat, they overproduce sweat for reasons doctors don’t fully understand.
The good news is that there are many different types of treatments for hyperhidrosis.
There are two types of hyperhidrosis:
- Primary hyperhidrosis: often an inherited disorder, which means a member of your family may have had it
- Secondary hyperhidrosis: caused by a condition, medications or behavior (like chronic alcoholism)
There are several places on the body that people experience hyperhidrosis:
- Palmar hyperhidrosis—excessive sweating of the hands
- Axillary hyperhidrosis—excessive underarm sweating
- Pedal Hyperhidrosis—excessive feet sweating. Sweating on the hands can be linked to feet sweating.
- Facial Hyperhidrosis/Blushing—flushing and sweating of the face
If your hyperhidrosis is caused by a family genetic predisposition, then it is unlikely that you will outgrow hyperhidrosis. The good news is there are many forms of treatment that you can explore with the doctors at Johns Hopkins.
Most of the time, by listening to a patient’s history, our doctors can diagnose hyperhidrosis. First, before they can recommend any treatments, they must rule out any other possibilities that could be causing the symptoms. Once those are ruled out, our doctors can also perform other tests, including a starch iodine test and a test using a device called a vapometer to determine how much sweat the different parts of your body makes.
We understand how much hyperhidrosis can affect your quality of life. Our doctors take treating hyperhidrosis very seriously, but always want to proceed in the safest manner possible when considering all treatments available. If your hyperhidrosis is moderate, many of these conservative treatments can help.
After determining that you have primary hyperhidrosis, you doctor will probably recommend conservative treatments first, before exploring surgery. Those conservative treatments include:
- Oral Medications: These medications, given by pill, are designed to affect your whole body, also called systemic treatment. These medications are known as anticholinergics; they cause whole body dryness, and may also cause irritating dry mouth and dry eyes.
- Topical Medications, such as Aluminum Chloride: This cream is applied in the evening. After applying it to your hands, or other affected areas, you cover the area and wear this protection over the area overnight. In the morning, the area should be dry.
- Iontophoresis: This form of electrical therapy can help people with hyperhidrosis of the hands and feet. You put your hands in water and an electrical current runs through the water. The electrical current minimizes the activity of the sweat glands. You must do this therapy 2-3 times a week for 20-30 minutes. There is a “recipe” on the Internet to create this device: DO NOT USE CAR BATTERIES AND PIE CRUST CONTAINERS to create iontophoresis treatment—that can be very dangerous.
- Botulinum Toxin: Known as Botox®, this medication can help with face, hand and underarm hyperhidrosis. It requires a number of shots, for example, the hand requires approximately 40 shots and many patients ask for local or general anesthesia. The effect typically lasts for 3-6 months. Please note that we do not offer Botox treatments.
- Microwave Thermolysis: During the procedure, your underarm skin is exposed to microwave energy and it destroys the sweat glands. The research from this device is very encouraging; some people have had dryness for up to two years now following the procedure. It typically takes 2-3 sessions over the course of three-six months.
Before the procedure, your doctor will numb the underarm area. Then your underarm skin is lifted into the system and microwave energy is directed to the sweat glands. The procedure typically takes an hour and involves no incisions or cuts; you should not feel any discomfort. After two treatments in our center, 95% of patients report a significant reduction in underarm sweat. You should be able to return to normal activities or work right away, and you can typically resume exercise within several days.
- If you have tried conservative treatments for hyperhidrosis and not had the level of success you had hoped for, your doctors may recommend surgical treatment, known as a sympathectomy or sympathotomy. A sympathectomy is removal of the sympathetic nerve; our doctors at Johns Hopkins prefer to cut the nerve instead of removing it. That is why we refer to the surgery as a sympathotomy.
- If you have not had your sweating for a long time, (arms, hands and feet), you will not be a surgical candidate for a sympathotomy. If you have truncal hyperhidrosis (sweating on your body or groin), you may also not be a good candidate for surgery.
- For treatment of hyperhidrosis, surgeons used to have to open the entire chest to locate and cut the sympathetic nerve, the nerve that controls the sweating reaction in people. Now we have VATS, which stands for Video Assisted Thoracic Surgery. Your surgeon makes a small incision in your underarm and using a small camera and light, is able to locate the sympathetic nerve and make the appropriate cuts. The increased magnified visualization of the sympathetic nerve offered by VATS eliminates the need to open up people’s chest.
- VATS gives our surgeons an amazing amount of precision, so they can localize the exact place on the nerve where the cut should be made.
- Surgeons also used to clip nerve with the idea that clip removal would make the surgery reversible: what they now know is that clipping is irreversible. To date, the best evidence suggests that clipping and cutting the nerve are fairly interchangeable although larger studies are needed to evaluate the two techniques head-to-head.
- Learn more about a sympathotomy.
The surgery is outpatient, which means you leave the hospital on the same day.
Patients are typically satisfied following their surgeries, with specific levels depending on where they first experienced hyperhidrosis. Patients undergoing surgery to treat sweating on their hands are usually the most pleased with results, with over 90% reporting satisfaction; those with excessive sweating in the underarm area or on their faces report a 70 to 80% satisfaction rate.
Compensatory sweating occurs when the original hyperhidrosis is no longer localized to the area where it first occurred. Often it can travel to the trunk or body or back of legs or knees and can occur after surgery. It doesn’t always occur right away; it can take about 6 weeks before we see this and doctors still don’t know why. What they do know is that the higher on the sympathetic nerve they have to cut, the more likely that compensatory sweating may happen, which is why now surgeons avoid cutting above rib 3.
There is a seasonal component with compensatory sweating. Our doctors at Johns Hopkins have noticed that patients get better in the winter, but experience more sweating in the summer.
When patients do suffer with compensatory sweating there are medications that are able to help.
Some doctors have tried experimenting with nerve grafts to try to reconnect the cuts that were originally made in the sympathetic nerve. However, none of these procedures seems to be successful. Therefore, it is important to understand that a sympathotomy is a permanent procedure and does carry risks.
Most health insurance plans do cover this surgery, but you need to check your individual policy. We find greater success in having insurance cover a sympathotomy when we can document that you have tried conservative therapies, including medication, iontophoresis, and Botox®. Once we show that we have tried other treatments, you can often appeal to your insurance company, which we will help you do.