Cranio-Facial Hyperhidrosis - Sweaty Face


Hyperhidrosis and Facial Blushing

- Hyperreactivity of the Sympathetic Nervous System -

Cranio-Facial Hyperhidrosis - Sweaty Face

alternate textAntonio Banderas in "Assassins"


It is estimated that of all the people suffering from hyperhidrosis, one in ten experiences it in the head region.

In patients with craniofacial hyperhidrosis, abnormal facial sweating, is triggered even by limited rise in temperature or mild physical exercise, developing especially on the forehead, the temporal region, frequently extending to the scalp and to the neck. Localized special forms of facial hyperhidrosis: nose, upper lip, Frey's syndrome.
For many sufferers, the sweat attacks represent a major burden, interfering with their self-confidence in social/professional contacts, in some cases leading to social isolation.

Basically, like in other forms of primary localized hyperhidrosis, the central control of the activity of the sweat glands seems to be overreactive. This results in too massive a response from the sympathetic nervous system, even to insignificant stimuli, leading to a disproportionate secretion of sweat. In many cases, a familiar predisposition can be found. The following sub-groups can be defined:
  1. Individuals extremely sensitive to temperature increases. Even a minor rise in outside temperature or minimal physical exercise trigger excessive sweating on the head. This is due to a non-optimal set or hypersensitively reacting "thermostat" in the hypothalamus (brain stem). Overweight can increase this tendency.
  2. Individuals reacting to psychological pressure, but less to temperature fluctuations.
  3. A combination of the two categories described above.


  • Antiperspirants:
    Solutions based on aluminum chloride should be applied with caution on the face. Contact with the eyes has to be avoided. The facial skin is relatively sensitive and may become irritated, requiring discontinuation of treatment. It is advisable to test the reaction of the skin by applying the product on a limited spot, before treating larger areas.
  • Botulinum Toxin:
    may be a useful method for the face if the surface to be treated is not too extended. The injections must be placed very superficially to avoid deeper diffusion into the mimic muscles which could cause loss of facial expression. Beware of injections close to the eyelids: if the substance diffuses into the eyelid, ptosis (drooping eyelid) may ensue, lasting weeks or even months.
    Especially useful is botulinum toxin for the treatment of rarer forms of focal facial hyperhidrosis, where other treatment options, including surgical measures, often fail: to nose wings, upper lip or in Frey's syndrome (unilateral sweating on the cheek after injury or surgery of the parotid gland, occurring while eating). Unfortunately, in these sites the injections tend to be more painful than elsewhere on the body. Particular attention is required when treating the upper lip, where the injections should be set as superficially as possible to prevent weakness of the lip.
  • Medication:
    Anticholinergic drugs which inhibit the sweat glands may be useful for occasional use. Due to their side effects (dry mouth, impaired vision, constipation, weakening of the bladder leading to voiding difficulties, etc.), these substances are difficult to tolerate in the long run.
  • Iontophoresis:
    for the treatment of facial hyperhidrosis, special foam masks covering head and face could be used. Prior to treatment, these masks should be well soaked in water to avoid burns. So far there are no large scale studies on the effectiveness of this method for the treatment of facial hyperhidrosis. Therefore the method has not become widespread.
  • Surgery:
    In cases of severe hyperhidrosis in the head area, immediate and definitive improvement can usually be achieved by sympathetic surgery. The procedure (ETS - Endoscopic Transthoracic Sympathectomy or ESB - Endoscopic Sympathetic Block) consists in interrupting the nerve with minimally invasive technique inside the chest cavity. Technical details, advantages and disadvantages are described in the dedicated chapter.
    For the treatment of facial hyperhidrosis it is important to limit the block to one single interruption of the sympathetic trunk in the interganglionic segment between T1 and T2. For this purpose, titanium clips should be used to compress the nerve (ESB), without severing it. In case of severe side effects (compensatory hyperhidrosis, circulatory problems), the clip can be removed, allowing at least for a partial recovery of the function of the nerve. For this reason, transection of the nerve (ETS) should be avoided. In any case, it makes no sense to interrupt several segments or even destroy a ganglion.
    Experience has shown that patients with facial hyperhidrosis due to pronounced temperature sensitivity are at a significantly higher risk to develop compensatory hyperhidrosis, following the procedure, than patients in whom sweat attacks are mainly triggered by emotional factors. For this reason, it has been proposed (Lin and Telaranta) to interrupt the sympathetic chain at the next lower level first, i.e. below the T2 ganglion. Unfortunately, this procedure has not produced sufficiently reliable results (own experience: >50% asymmetric or insufficient effect on the head, or early relapses). Therefore, the author prefers an interganglionic block between T1 and T2 using clips. In our own study, the clips had to be removed in 12.5% after ESB, due to extreme compensatory sweating.
    In summary: patients with facial hyperhidrosis run a significantly higher risk for developing compensatory hyperhidrosis after sympathetic surgery than patients treated for other types of hyperhidrosis. Therefore, in this category of patients, all other treatment options should be tried before considering surgery.