Compensatory Hyperhidrosis


Also known as … Rebound Sweating, Post Endoscopic Thoracic Sympathectomy (ETS) Sweating, Paradoxical Sweating, Reflex Sweating

What is Compensatory Hyperhidrosis?

Compensatory Hyperhidrosis is a common, post-surgical complication of endoscopic thoracic sympathectomy (ETS surgery).

The condition occurs mainly on the trunk and can affect large areas of the body.

Compensatory hyperhidrosis most often occurs after ETS surgery. It generally occurs in areas such as the back or lower limbs, weeks to months after the operation.

Compensatory hyperhidrosis can also occur because of nerve damage in conditions such as diabetes, brain injury and syringomyelia. It is sometimes called “phantom sweating” in nerve damage following accidents and amputation surgery.

Compensatory hyperhidrosis has been reported following botox (botulinum toxin A) injections for axillary hyperhidrosis. However, it is extremely rare and usually resolves within 4 to 6 months.

The areas affected can be small or large. The most frequently affected areas include the chest, flanks, abdomen and back. The lower limb and buttock areas can also be involved.


Most cases of compensatory hyperhidrosis occur as the result of ETS surgery. Other rare causes include:

  • diabetes
  • brain injury
  • spinal cord disease
  • limb amputation.

The diagnosis is made when there is a clear history of ETS surgery prior to the presentation of sweating.

Compensatory hyperhidrosis can be difficult to treat. The chosen method of treatment will depend on how localised and severe the sweating is.

  • Topical treatments

Mild cases can respond to topical treatments such as aluminium chloride hexahydrate (Driclor). Driclor should always be applied to skin that is as dry as possible in order to maximise the benefit and minimise potential side effects. Ideally, it should be applied just after a shower prior to bedtime. Dry the area off with a hairdryer on the cool setting then apply Driclor. Wash the area with plain water in the morning. If irritation develops, applying a corticosteroid cream can be useful (this needs to be used under the guidance of a medical professional).

Anticholinergic creams, lotions and sprays such as glycopyrolate (0.5-3%) can be effective in managing compensatory hyperhidrosis. A compounding pharmacist can make up these creams.

  • Botulinum toxin type A injections

Botox injections can be used safely and effectively to treat certain, localised cases of compensatory hyperhidrosis or rebound sweating. This treatment is not subsidised under Medicare-PBS.

  • Oral medication

Anticholinergic tablets (such as oxybutynin and propantheline bromide) can be useful in treating compensatory hyperhidrosis. However, side effects such as constipation, dry mouth and drowsiness are common.

Other medications reported to be useful include oral glycopyrrolate (not available in Australia), propranolol, clonazepam and gabapentin.

Taking medications for a few weeks can give people “a break” from the psychological and physical distress of compensatory sweating.

Compensatory hyperhidrosis will often need ongoing and persistent treatment. However, some people may notice the amount of sweating decreases as they get older.

This information has been written by Dr Davin S. Lim


2019 © Australasian College of Dermatologists.

You may use for personal use only. Please refer to our disclaimer.