Primary focal hyperhidrosis and autonomic symptom burden: a case–control study using the COMPASS-31 questionnaire

Purpose: To explore the relationship between primary focal hyperhidrosis (PFH) and generalized autonomic dysfunction, we assessed autonomic symptom burden using a comprehensive and validated measure of autonomic symptoms. Methods: In this case–control study, we compared 132 patients with PFH with 74 matched healthy controls. Autonomic symptoms were assessed using the Composite Autonomic Symptom Score-31 (COMPASS-31) questionnaire. Propensity score matching minimized confounding. Mann–Whitney U tests compared COMPASS-31 scores between groups. A sensitivity analysis using multivariate linear regression accounted for specific hyperhidrosis sites and demographic factors. Results: PFH cases demonstrated significantly higher median COMPASS-31 scores compared to controls (18.7 [IQR 7.7–34.8] vs. 11.2 [IQR 3.5–19.3], p < 0.001). Significant differences were observed in orthostatic (2.0 [0–20] vs. 0 [0–12], p = 0.028), vasomotor (0 [0–0] vs. 0 [0–0], p = 0.005; 24.2% vs. 9.5% non-zero scores, respectively), secretomotor (3.2 [2.1–8.6] vs. 0 [0–3.8], p < 0.001), and gastrointestinal (5.4 [1.8–8] vs. 1.8 [0.9–5.4], p = 0.004) domains. Sensitivity analysis confirmed PFH status as a significant predictor of higher COMPASS-31 scores (additional 7.5 points on average, 95% CI 1.6–13.4, p = 0.012) after adjusting for demographic factors and hyperhidrosis sites. Craniofacial and truncal hyperhidrosis were associated with higher autonomic symptom burden. Conclusion: PFH is associated with a broader spectrum of autonomic symptoms beyond localized sweating, establishing a link to more generalized autonomic dysfunction. These findings underscore the need for a comprehensive approach to evaluating and managing patients with PFH.