Centre for Medical and Surgical Dermatology
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Hyperhidrosis Disease Severity Scale

Patient-Reported Severity Scale

Rate hyperhidrosis severity with the HDSS, the single-item patient scale from 1 (never noticeable) to 4 (intolerable). Records the treated site and reports the 1-point and 2-point improvements from baseline used as trial responses.

About

About the HDSS

Severity Bands

Score RangeClassification
1 – 2Mild or moderate
3 – 4Severe

Clinical Background

The Hyperhidrosis Disease Severity Scale (HDSS) is a single-item, patient-reported measure of the functional impact of focal hyperhidrosis. It was developed with the support of Allergan during the botulinum toxin type A axillary hyperhidrosis programme and validated by Kowalski et al. (2004) against the Dermatology Life Quality Index, the Hyperhidrosis Impact Questionnaire and gravimetric sweat measurement, with a test-retest reliability coefficient of 0.82. The Canadian Hyperhidrosis Advisory Committee adopted the scale as the basis of its severity-based treatment recommendations (Solish et al. 2007), and it has since been the most widely used severity measure in hyperhidrosis practice and clinical trials.

The patient is asked how severe the sweating of a specified body area is and selects one of four statements: sweating that is never noticeable and never interferes with daily activities (1), tolerable but sometimes interfering (2), barely tolerable and frequently interfering (3), or intolerable and always interfering (4). The validation study and the botulinum toxin trials worded each statement as underarm sweating; the Canadian recommendations and the International Hyperhidrosis Society distribute the generic wording used here, which applies the same statements to any focal site. The site being rated is recorded alongside the grade but does not enter the score.

A score of 1 or 2 indicates mild or moderate and a score of 3 or 4 severe primary hyperhidrosis, and the Canadian treatment algorithms branch on that division. In the botulinum toxin trials a 1-point improvement in the HDSS was associated with about a 50% reduction and a 2-point improvement with about an 80% reduction in gravimetrically measured sweat production (Solish et al. 2007). A 2-point improvement from baseline was the responder definition of the 52-week botulinum toxin type A trial (Lowe et al. 2007) and a secondary endpoint of the topical glycopyrronium tosylate (Glaser et al. 2019) and sofpironium bromide (Kirsch et al. 2020) programmes, and reaching a score of 1 or 2 is the practical treatment goal.

The HDSS captures the patient's perception of interference with daily activities rather than the quantity of sweat, so it complements rather than replaces gravimetry, the starch-iodine test or quality of life instruments. It is a four-point scale with no intermediate values, it is not site-specific in its wording, and it has been used almost exclusively in adults. In Canada an HDSS score of 3 or 4 after failure of topical antiperspirants is the usual criterion in public and private reimbursement of botulinum toxin for axillary hyperhidrosis.

References

  1. Kowalski JW, Eadie N, Dagget S, Lai PY. Validity and reliability of the hyperhidrosis disease severity scale (HDSS). J Am Acad Dermatol. 2004;50(3):P51. doi:10.1016/j.jaad.2003.10.202
  2. Solish N, Bertucci V, Dansereau A, Hong HC, Lynde C, Lupin M, et al.. A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007;33(8):908-923. doi:10.1111/j.1524-4725.2007.33192.x
  3. Lowe NJ, Glaser DA, Eadie N, Daggett S, Kowalski JW, Lai PY. Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. J Am Acad Dermatol. 2007;56(4):604-611. doi:10.1016/j.jaad.2007.01.009
  4. Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. 2004;51(2):241-248. doi:10.1016/j.jaad.2003.12.040
  5. Hornberger J, Grimes K, Naumann M, Glaser DA, Lowe NJ, Naver H, et al.. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004;51(2):274-286. doi:10.1016/j.jaad.2003.12.029
  6. Glaser DA, Hebert AA, Nast A, Werschler WP, Green L, Mamelok R, et al.. Topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis: results from the ATMOS-1 and ATMOS-2 phase 3 randomized controlled trials. J Am Acad Dermatol. 2019;80(1):128-138.e2. doi:10.1016/j.jaad.2018.07.002
  7. Kirsch B, Smith S, Cohen J, DuBois J, Green L, Baumann L, et al.. Efficacy and safety of topical sofpironium bromide gel for the treatment of axillary hyperhidrosis: a phase II, randomized, controlled, double-blinded trial. J Am Acad Dermatol. 2020;82(6):1321-1327. doi:10.1016/j.jaad.2020.02.016

Development

The clinical calculators on this site are free to use. They were developed in partnership by the Centre for Medical and Surgical Dermatology and Dermi(opens in a new tab), a Toronto company that makes clinical imaging software for dermatology practices, which continues to maintain them.

Frequently Asked Questions about the HDSS

The Hyperhidrosis Disease Severity Scale (HDSS) is a single-question, patient-reported scale of how much excessive sweating interferes with daily activities. The patient selects one of four statements, scored 1 (sweating never noticeable, never interfering) to 4 (intolerable, always interfering). It was validated by Kowalski et al. in 2004 and adopted by the Canadian Hyperhidrosis Advisory Committee in 2007.
An HDSS score of 3 or 4 indicates severe primary hyperhidrosis, and a score of 1 or 2 indicates mild or moderate disease. The Canadian treatment recommendations branch on this division: topical antiperspirants are first-line at every grade, and botulinum toxin, iontophoresis, systemic agents or procedural treatments are considered for severe disease or after topical failure.
A 2-point improvement means the HDSS score has fallen by two grades from baseline, for example from 4 to 2. In the botulinum toxin trials a 2-point improvement was associated with about an 80% reduction in measured sweat production and was the definition of a treatment responder. A 1-point improvement was associated with about a 50% reduction.
The scale was validated in axillary hyperhidrosis with statements worded as underarm sweating, but the Canadian recommendations and the International Hyperhidrosis Society distribute a generic version that asks about the sweating of a specified body area. It is used in practice for palmar, plantar, craniofacial and other focal sites, and this calculator records the site alongside the grade.
Most Canadian public and private drug plans require documentation of severe primary axillary hyperhidrosis, generally an HDSS score of 3 or 4 that has not responded to topical antiperspirants, before covering botulinum toxin type A. Reassessment with the HDSS after treatment documents the response and supports continued coverage.

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