Clinical Best Practices and Insights Toward Improving Recognition, Diagnosis and Treatment of Primary Axillary Hyperhidrosis (PAH)

Abstract

Background: Primary axillary hyperhidrosis (PAH) is an underdiagnosed and underreported condition with symptoms beginning before age 25. We ​conducted​ a literature review and informal interviews with dermatology healthcare providers (HCPs) to understand how PAH is identified, diagnosed and treated​,​ and to ​identify ​best practices for optimizing patient-centric PAH care. 

Methods: A search was ​performed ​on PubMed with the following terms: “hyperhidrosis,” and “diagnosis,” and/or “prevalence,” and/or “quality of life” and “dermatology visits” and “United States;” an additional search queried “factors influencing topical drug compliance,” from January 2015 to August 2025.  

From June–July 2025, five dermatology healthcare providers (HCPs) participated in unstructured discussions about best practices.  

Results: Literature Key Insights: PAH symptoms appear around puberty/young adulthood, and diagnosis is often delayed. PAH is described as an “underreported” or “underdiagnosed” condition, a “silent” condition with patients “suffering unnecessarily.”  PAH affects 10 million Americans yet​​ ​remains uncited​ as a primary reason for dermatology visits; for those <18 years, most visits were for acne, skin rash, or warts, with females more likely to seek dermatology care. Reasons for PAH underdiagnosis included: lack of awareness, embarrassment, and/or communication issues/lack of HCP time. Delayed/lack of PAH treatment is associated with diminished quality of life (QoL), psychosocial distress, and functional or physical impairment. PAH topical medication regimens may be susceptible to non-adherence obstacles​,​ adversely affecting treatment outcomes. 

HCP discussions revealed ​​congruence​​ with literature findings regarding initial PAH recognition and treatment obstacles. The following clinical insights and best practices were identified: 

Best Practice 1: Increase PAH recognition and diagnosis: Provide PAH disease state educational resources in the waiting area to help patients self-identify PAH and use the Hyperhidrosis Disease Severity Scale (HDSS) to screen all patients, especially <25 years. PAH patients tend to schedule dermatology visits for evaluation/treatment of other skin conditions. PAH educational material may foster conversations about excessive sweating. The HDSS, a validated, single-item diagnostic tool, may capture patients who would otherwise be undiagnosed.  

Best Practice 2: Use the ABCs to recognize PAH symptoms: Age of onset; Bilateral; Cessation during sleep; Duration of sweat episodes, ​≥​2/week over 6 months; Episodes vary in frequency and severity; Family, often a blood relative had/has symptoms; Gets in the way, interfering with activities and QOL. 

Best Practice 3: Initiate conversations: Patients may be hesitant to initiate a conversation due to embarrassment or lack of awareness that PAH is a treatable disease. Reassure the patient that PAH symptoms are a “real” medical condition and treatable. 

Best Practice 4: Use a patient-centric shared decision-making approach to PAH treatment selection: Review various treatment options. Recommend treatments that promote regimen adherence by selecting therapies, such as sofpironium gel, 12.45%, to address cost, convenience, access, regimen frequency and complexity, potential severity of side effects​,​ and efficacy. 

Best Practice 5: Raise awareness: PAH is as common as psoriasis but underrecognized. Sharing best practices through case presentations fosters increased awareness. 

Conclusion: Sharing best practices may improve PAH awareness and treatment in real-life settings.