What is the initial approach to a 14-year-old patient presenting with hyperhidrosis at a dermatology clinic?

Essential History Questions for a 14-Year-Old with Hyperhidrosis

Begin by determining whether this is primary focal hyperhidrosis or secondary generalized hyperhidrosis, as this distinction fundamentally changes your diagnostic and therapeutic approach. 1

Characterization of Sweating Pattern

Ask about the anatomic distribution of sweating to distinguish primary from secondary hyperhidrosis:

• Is the sweating bilateral and symmetric, affecting specific areas like armpits, palms, soles, or face? This pattern suggests primary focal hyperhidrosis, which accounts for approximately 93% of hyperhidrosis cases 1
• Is the sweating generalized, asymmetric, or affecting unusual body areas? This raises concern for secondary causes requiring investigation 1
• Does the sweating occur during sleep? Nocturnal sweating is a red flag for secondary hyperhidrosis, as primary focal hyperhidrosis typically does not occur during sleep 2, 1

Assess the age of onset and duration:

• When did the excessive sweating first start? Primary focal hyperhidrosis typically begins in childhood or adolescence 1
• Has the pattern changed recently or worsened suddenly? Acute onset or rapid progression suggests secondary causes 1

Severity Assessment Using Validated Tools

Use the Hyperhidrosis Disease Severity Scale (HDSS) to quantify impact 2, 3:

• "How would you rate your sweating: barely noticeable and never interferes with daily activities (score 1), tolerable but sometimes interferes (score 2), barely tolerable and frequently interferes (score 3), or intolerable and always interferes with daily activities (score 4)?" 3
• This score directly guides treatment selection, with scores of 3-4 indicating severe disease requiring more aggressive first-line therapy 3

Screening for Secondary Causes (SCREeN Approach)

The American Academy of Dermatology recommends systematic screening using the "SCREeN" framework 4:

Sleep disorders:

• "Do you have trouble sleeping, snore loudly, or wake up gasping for air?" Sleep apnea can cause secondary hyperhidrosis 4

Cardiovascular conditions:

• "Do you experience chest pain, rapid heartbeat, or palpitations?" Cardiac conditions may present with sweating 4

Renal disease:

• "Have you noticed changes in urination, swelling in your legs or face?" Kidney disease can cause secondary hyperhidrosis 4

Endocrine disorders (particularly important in adolescent females):

• "Have you experienced unintentional weight changes, feeling excessively hot or cold, tremor, or changes in your menstrual periods?" These symptoms suggest hyperthyroidism, diabetes, or pheochromocytoma 4
• "Have you noticed irregular periods, excessive facial or body hair, or acne?" Screen for polycystic ovarian syndrome, which is associated with hidradenitis suppurativa in adolescent females 4

Neurological conditions:

• "Have you had any recent head injuries, seizures, or neurological symptoms?" Neurological disorders can cause autonomic dysfunction 4

Medication and Substance History

Ask about all medications and substances:

• "Are you taking any prescription medications, over-the-counter drugs, or supplements?" Many medications cause secondary hyperhidrosis 1
• "Do you use caffeine, alcohol, or any recreational substances?" These can trigger or worsen sweating 1

Associated Dermatologic Conditions

Screen for hidradenitis suppurativa, which has increased prevalence in adolescent females 4:

• "Do you get painful bumps, boils, or draining lesions in your armpits, groin, or buttocks?" 4
• "Do you have acne on your face, chest, or back?" Acne can coexist with hidradenitis suppurativa 4

Psychosocial Impact Assessment

Depression and anxiety are common comorbidities with chronic dermatologic conditions 4:

• "Do you feel sad, anxious, or worried frequently?" 4
• "Has the sweating affected your ability to participate in school, sports, or social activities?" 2, 5
• "Have you ever had thoughts of hurting yourself?" Screen for suicidality, particularly important in chronic skin conditions 4

Family History

Ask about family history of hyperhidrosis:

• "Does anyone in your family have excessive sweating?" Primary focal hyperhidrosis often has a genetic component 1

Red Flags Requiring Immediate Investigation

Watch for these concerning features that mandate urgent workup:

• Palpitations, tremor, or heat intolerance suggest hyperthyroidism requiring immediate thyroid function testing 4
• Unilateral or asymmetric sweating raises concern for neurological pathology 1
• Night sweats with fever or weight loss suggest infection or malignancy 1
• Recent medication changes temporally associated with sweating onset 1

Quality of Life Impact

Quantify the functional impairment:

• "Does sweating cause you to avoid shaking hands, using touch screens, or participating in activities?" 2, 5
• "Do you change clothes multiple times per day or avoid certain clothing?" 5
• "Has this affected your school performance or social relationships?" 5

Common Pitfalls to Avoid

• Do not assume all adolescent sweating is "normal puberty" without assessing severity and impact on quality of life 2, 5
• Do not miss secondary causes by failing to ask about nocturnal sweating, which essentially rules out primary focal hyperhidrosis 1
• Do not overlook the psychosocial burden of hyperhidrosis, which can be profound and warrants screening for depression and anxiety 4, 5
• Do not forget to screen for hidradenitis suppurativa in adolescent females presenting with axillary hyperhidrosis, as these conditions frequently coexist 4