Real sweating in a virtual stress environment: Investigation of the stress reactivity in people with primary hyperhidrosis.

Adrian E Linden (1), Katharina Dietrich (1), Ulrike Winnikes (1), Gregor Domes (2), Jobst Meyer (1), Patrick Zimmer (2),
Andrea B
Schote (1)
(1) Departement of Neurobehavioral Genetics, Institute of Psychobiology, University of Trier,Germany;
(2) Department of Biological and Clinical Psychology, University of Trier, Germany
July 2019, Psychoneuroendocrinology 107, DOI: 10.1016/j.psyneuen.2019.07.080


Hyperhidrosis (excessive sweating, OMIM %114110) is a complex disorder with multifactorial causes and an increased accurrance of social anxiety (1). In terms of a vicious circle, emotional strains cause of anticipatory fear in social-evaluative situations can enhance sweating and vice versa (2,3). Even though previous studies find higher depression and social anxiety scores, the cortisol awakening response (CAR) in hyperhidrotics seems to have a normal pattern (4). With regard to sweat secretion, cortisol concentrations and subjective stress ratings, we investigated the acute stress reaction in response to (virtual) Trier Social Stress Test (VR-TSST).



In this pilot study, we conducted VR-TSSTs under controlled conditions and performed general linear models with repeated measurements for cortisol levels, axillary sweat and subjective stress ratings for two groups (diagnosed hyperhidrotics (N=10), healthy controls (N=33)). All hyperhidrotics were diagnosed by physicians and additionally filled the hyperhidrosis impact questionnaire (HHIQ).


Hyperhidrotics showed significantly heightened sweat secretion over time compared to controls (F(1.643, 67.361) = 6.020, p = 0.006), with highest quantities during the VR-TSST.

Fig. 1:

Mean axillary sweat production before, during and after the VR-TSST for subjects with a diagnosed and not diagnosed hyperhidrosis. 

In both groups, sweating (F(1.643, 67.361) = 55.834, p < 0.001), maximum cortisol levels (F(1.653, 67.673) = 14.258, p < 0.001), physical discomfort (F(2.907, 119.185) = 11.134, p < 0.001) and feelings of stress (F(3.041, 121.624) = 22.173, p < 0.001) increased significantly in response to the VR-TSST.

Fig. 2:

Mean cortisol concentration in participants with or without a diagnosed hyperhidrosis seven times. The time of measurement is based on the onset of the VR-TSST.

No differences were detected in cortisol concentrations and subjective ratings between hyperhidrotics and controls (pall > 0.219).

Fig. 3:

Mean scores of the subjective stress of participants with or without a diagnosed hyperhidrosis. The time of measurement is based on the onset of the VR-TSST.


Contrary to the assumption, hyperhidrotics don‘t show a higher objective or subjective stress reaction. With regard to the underlying results it seems that the development and maintenance of the psychophysical disorder hyperhidrosis is not traceable to an altered reactivity of the hypothalamus-pituitary-adrenal axis. As an other option the explanation for excessive sweating might be investigated in the sympathomedullary pathway for stress reaction. Future studies might consider the sympathetic nervous system as another potential pathway involved in the stress reactivity of hyperhidrotics.


1Bahar, R., Zhou, P., Liu, Y., Huang, Y., Phillips, A., Lee, T. K. et al. (2016). The prevalence of anxiety and depression in patients with or without hyperhidrosis (HH). Journal of the American Academy of Dermatology, 75(6), 1126-1133.; 2Böni, R. (2001). Schwitzen und Hyperhidrose (gesteigerte Schweisssekretion). Swiss Medical Forum ‒ Schweizerisches Medizin-Forum, (18), 464–467.; 3Romero, F. R., Haddad, G. R., Miot, H. A. & Cataneo, D. C. (2016). Palmar hyperhidrosis: clinical, pathophysiological, diagnostic and therapeutic aspects. Anais Brasileiros De Dermatologia, 91(6), 716–725.; 4Gross, K. M., Schote, A. B., Schneider, K. K., Schulz, A. & Meyer, J. (2014). Elevated social stress levels and depressive symptoms in primary hyperhidrosis. PloS One, 9(3), e92412.