“My hands and armpits drip with sweat even when I’m not hot — it’s ruining my work and my confidence”

PRIMARY FOCAL HYPERHIDROSIS is excessive LOCALISED sweating of the PALMS, SOLES, AXILLAE and/or face, typically BILATERAL and SYMMETRICAL, with onset in childhood/adolescence, occurring even when the person is not hot but characteristically STOPPING during SLEEP, often with a family history and worsened by stress — a benign, recognised condition. Distinguish it from SECONDARY (often generalised) hyperhidrosis, whose red flags warrant a work-up: generalised or asymmetric sweating, NIGHT sweats, weight loss, later-life onset, or systemic symptoms — prompting consideration of hyperthyroidism, infection (including TB), malignancy/lymphoma, menopause, diabetes/hypoglycaemia, anxiety, phaeochromocytoma and drugs. Manage primary focal hyperhidrosis STEPWISE: first-line topical ALUMINIUM CHLORIDE hexahydrate 20% (BNF), applied to completely dry skin at bedtime and washed off in the morning, then iontophoresis (especially palms/soles), topical anticholinergics (glycopyrronium — specialist or local formulary use only), oral anticholinergics (propantheline, dose per BNF; oxybutynin off-label — weighing side-effects), and BOTULINUM TOXIN A injections (effective for severe axillary hyperhidrosis; specialist), with practical advice (absorbent clothing, sweat shields) and severity scored with the HDSS (International Hyperhidrosis Society, international; 3 or 4 = severe). Refer to dermatology for severe/refractory cases or specialist treatments, and consider surgery (endoscopic thoracic sympathectomy, NICE HTG339, formerly IPG487) in carefully selected severe upper-limb cases after other treatments, with counselling that compensatory sweating is usual and can be severe; treat any identified secondary cause. Crucially, acknowledge the major psychosocial impact (confidence, work, social life, relationships, anxiety) and validate that this is a treatable medical condition, not a hygiene failing. The skill is recognising primary focal hyperhidrosis, excluding secondary red flags, stepwise treatment, referral if severe, and addressing the impact.