Report

Quantification of sweat secretion in focal axillary

hyperhidrosis related to area and time: the hyperhidrosis
area and secretion index
Friedrich A. Bahmer, MD

€r Dermatologie, Bremen,
Privatpraxis fu Abstract
Germany Background Severity of focal axillary hyperhidrosis (FAH) hitherto is estimated
semiquantitatively by weighting the secreted sweat with the sweating area visualized by
Correspondence
Friedrich A. Bahmer, MD
iodine starch test. In this study, we quantified secretion (mg/cm2 per min) simply by
Privatpraxis fuer Dermatologie estimating the sweating area morphometrically via point counting. We have named the
Soegestrasse 55-57 numeric value obtained the hyperhidrosis area and secretion index (HASI).
28195 Bremen Methods In 183 patients (146 women, 37 men) with focal axillary hyperhidrosis, seen in a
Germany
city hospital outpatient clinic, sweat secretion was assessed by gravimetry and the area of
E-mail: fbahmer@t-online.de
Minor’s iodine–starch test determined by point counting. Values were analyzed with respect
Conflicts of interest: None. to gender, age, and body surface area.
Results HASI values, combined for both axillae, ranged from 0.21 to 22.8 mg/cm2 per
minute with only minor gender differences. Men had larger sweating areas than women
did. The comparison of left to right side axillae did not disclose substantial differences. No
correlation was found between age and HASI values. A subgroup analysis of 91 patients
showed a good correlation of HASI values with body surface area.
Conclusion HASI allows for a quantification of sweat secretion per time interval and area
unit, thus facilitating pre- and post-test assessment of sweat intensity as well as a
comparison between the results of different studies.

difference between the two weights was recorded as sweat

Introduction
In focal hyperhidrosis, sweating intensity is assessed by
gravimetry, and the sweating area is visualized by
Minor’s iodine–starch test.1 To obtain an estimate of sweat
secretion related both to secretion time as well as to sweating
area, we combine gravimetry with sweating area estimation
by point counting. This allows the calculation of sweat
secretion (mg/cm2 per min), yielding the hyperhidrosis area
and secretion index (HASI).2 We have replaced the term
“severity” in the original HASI description2 by the more
appropriate term “secretion.”
Methods
Gravimetry was performed after 30 minutes at rest at ambient
room temperature between 20 and 22 °C, and at least two
hours after food intake. After wiping the axilla twice with an
ordinary cosmetic tissue, a wedge-shaped coffee filter paper
(Melitta, Minden, Germany), weighted with a microbalance
€ ttingen, Gemany) to a
(Sartorius BP 121 S; Sartorious AG, Go
precision of 1 mg, was placed under the axilla. After five
minutes, the filter paper was removed and weighted again. The
production in milligrams over five minutes. Subsequently, the
sweating area was stained using Minor’s iodine–starch test, and
the dark blue stained area was determined by point counting
with a superimposed square lattice grid, made by copying a
drawing on a transparent foil (Fig. 1). For the sake of ease and
speed, we used a transparent grid with grid lines 1 cm apart.3
With square lattice grid lines 1 cm apart, the number of
crossover points within the boundaries of the area estimated
equals their size in square centimeters.3,4 As the areas
measured in focal axillary hyperhidrosis are of low complexity,
the old point-counting principle allows for remarkable precision,
even using a rather coarse grid.4 HASI was calculated by
dividing the total amount of sweat secretion (Stot; in milligrams)
by time (T; in min) and by area (A; in square centimeters); in a
formalized manner, HASI = Stot/T 9 A (mg/min 9 cm2). This
calculation can be done by hand or by pocket calculator. Area
estimation by point counting is possible independently from the
shape of the area to be assessed. If the iodine–starch test
yields patchy stained areas, simply the number of crossover
points on the stained patches is counted.
Statistical analysis was performed by Statgraphics centurion
version XVI (StatPoint Technologies, Inc., Warrenton, VA, 1233

ª 2015 The International Society of Dermatology International Journal of Dermatology 2015, 54, 1233–1235
1234 Report Hyperhidrosis area and secretion index (HASI) F. A. Bahmer

patients (146 women, 37 men), complete data on the main

variables age, gender, gravimetry, and area of the Minor test
were available. Only from the last 91 (49.7%) patients of this
series, body weight and height were recorded allowing
calculation of body surface area as well as body mass index.
Other data such as smoking habit were only incompletely
recorded and thus were not taken into account.

Figure 1 Minor iodine starch test. Axilla with square lattice
grid superimposed. One crossover point of the grid lines
(distance 1 cm) represents 1 cm2, the 34 points on the
stained area 34 cm2 accordingly
USA). Gender differences were assessed with the F-test, and
Pearson’s product-moment correlation was calculated for
correlation analysis of body surface area and HASI score with
the sweating area values transformed logarithmically due to
skewed distribution.
Subjects
We investigated 197 unselected patients (155 women, 42 men)
complaining of excessive axillary sweating seen in our
department within a 2.5 year period. Diabetes and thyroid
disease were ruled out by history taking. From 183 (92.9%)
Results
The results are shown in the Table 1. Females dominated
our sample, accounting for almost 80% of the patients.
Age range for both men and women was similar (women
14–53 years, mean 26.2; men 14–55 years, mean 26.9).
Summarized for both axillae and for both sexes, the HASI
score ranged from 0.21 to 22.8 (mean 4.50) mg/cm2 per
minute, with lower values for women (0.21–22.8, mean
4.41) than for men (0.60–15.7, mean 4.86) but with a
broader range for HASI values in women. No correlation
was found between age and HASI values.
The size of sweating areas of both axillae was
comparable in both genders: women 6–132 cm2, men
11–136 cm2 with higher mean values in men (37.1
cm2) than in women (25.6 cm2). This difference is sta-
tistically significant (F-test, quotient 9.46, P = 0.0024).
No substantial interindividual difference between the
sweating area of the left and the right axilla was
encountered. In the subgroup analyzed for correlation
of HASI values and body surface area, a positive corre-
lation was found (Pearson product-moment correlation;
r = 0.89, P = 0.0040).

Table 1 Hyperhidrosis area and secretion index (HASI): subject characteristics and measurement values

Patients, no. (%)

Variable Female, 146 (79.8) Male, 37 (20.2) Total, 183 (100.0)

Age range, mean (SD), years 14–53, 26.2 (7.54) 18–55, 29.6 (9.60) 14–55, 26.9 (8.26)
HASI values,a range, mean (SD) 0.21–22.8, 4.41 (3.65) 0.60–15.7, 4.86 (3.15) 0.21–22.8, 4.50 (3.55)
Gravimetry,b mean (SD) 2.0–315.0, 52.8 (50.8) 8.2–269.5, 83.5 (66.7) 2.0–315.0, 58.9 (55.5)
Axillary area,b mean (SD), cm2 6–132, 25.6 (15.1) 11–136, 37.1 (25.0) 6–136, 27.9 (18.1)
BSA, n (%) 65 (71.4) 26 (28.6) 91 (100.0)
BSA, range, mean (SD), m2 1.46–2.16, 1.74 (0.18) 1.68–2.27, 2.02 (0.18) 1.46–2.27, 1.82 (0.21)
BMI, range, mean (SD) 17.3–32.2, 22.5 (3.04) 18.2–30.8, 24.8 (3.19) 17.3–32.2, 23.2 (3.24)

Site comparison Left axilla Right axilla Both axillae

Area, mean (SD), cm2 2–80, 13.8 (10.0) 3–68, 14.1 (8.6) 6–136, 27.9 (18.1)
Secretion, mean (SD), mg 0.2–144.4, 28.1 (27.6) 0–175.0, 30.8 (29.0) 2.0–315.0, 58.9 (55.5)
HASI values, range, mean (SD) 0.20–13.5, 2.32 (1.91) 0.01–9.3, 2.17 (1.75) 0.21–22.8, 4.50 (3.55)

BMI, body mass index; BSA, body surface area; HASI, hyperhidrosis area and secretion index.
a
(mg 9 cm 1 9 min 1), both axillae.
b
Both axillae.

International Journal of Dermatology 2015, 54, 1233–1235 ª 2015 The International Society of Dermatology
F. A. Bahmer
Discussion
5 tion curettage, or botulinum toxin injections.
FAH of the axillae is not a rare disease. Both sexes
are afflicted, but no data are available with respect to
gender ratio. In our sample, females predominated.
Hyperhidrosis in general is characterized by sweat
secretion above physiological needs.5 The amount of
secretion is usually assessed semiquantitatively by gra-
vimetry with the sweating area visualized by Minor
iodine–starch test. No attempt has been made so far to
assess the size of the sweating area; only a method for
semiquantitative visual assessment of the Minor test has
been published.6 To avoid quantification problems, in
general it has been proposed to get disease severity
assessed solely by patients using a hyperhidrosis severity
scale.7
Gravimetry could be complemented by estimating the
sweating area visualized by Minor iodine–starch test mor-
phometrically with a superimposed square lattice grid,
allowing quantification of sweat secretion (mg/cm2 per
min) as HASI.2 Based on an analysis of 183 patients with
FAH, the result of HASI quantification is presented. The
gravimetric values obtained in our study correspond to
those reported by Hund et al.8 In their study, mean val-
ues of 69.2 mg/min sweat (men) and 37.4 mg/min
(women) were obtained. Our mean values are somewhat
lower with 66.7 mg/min (men) and somewhat higher for
women with 50.8 mg/min. These slight differences might
be due to differences in assessment methods or in patient
cohorts.
No cut-off value exists between normal and pathologic
sweating. Based on our study, we arbitrarily regard HASI
values of more than 0.5 mg/cm2 per minute in a single
axilla as hyperhidrotic. Because psychophysiological
aspects9 are important in FAH and even patients with
minimal secretion suffer considerably, not only the
amount of sweat secreted should be taken into account.
In Germany, health insurance companies require quantita-
tive assessment of sweat secretion in patients who
ª 2015 The International Society of Dermatology
Hyperhidrosis area and secretion index (HASI) Report 1235
demand costly treatment procedures such as surgery, suc-
It should be mentioned that the HASI method described
might be used for focal hyperhidrosis elsewhere on the
body. The combination of gravimetry, iodine–starch test,
and morphometry thus can facilitate quantification of
sweat secretion without costly equipment.
References
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International Journal of Dermatology 2015, 54, 1233–1235