Sjögren’s disease typically declares itself through a familiar triad of symptoms: dryness of the mouth and eyes, fatigue, and joint pain. These three complaints appear in more than 80 percent of patients, which is why the condition is usually flagged by dentists detecting rampant cavities or ophthalmologists noting parched corneas. Roughly 55 percent of patients also experience symptoms of autonomic nervous system dysfunction, and reduced sweating has been documented as a statistically significant finding compared with healthy controls. Yet generalized anhidrosis, the near-complete loss of sweating across the body, as the first and dominant manifestation of Sjögren’s is exceedingly rare. The new report describes one of the most detailed accounts of such a presentation, complete with a decade-long timeline and sophisticated pathological analysis of the patient’s sweat glands.

The diagnostic journey began when the woman presented to the dermatology department complaining of decreased sweating throughout her body. She had a history of a pituitary tumor, but ten years of progressive hypohidrosis had gone uninvestigated. Physical examination revealed no skin rash and no episodes suggestive of cholinergic urticaria, the itchy hives that often accompany sweating disorders. The pivotal clue came from the Minor’s test, a classic technique in which iodine and starch powder are applied to the skin; where sweat emerges, the mixture turns dark blue. In this patient, the test revealed anhidrosis covering 98 percent of her body surface area, leaving only small islands of functional sweat production.

Laboratory work narrowed the differential diagnosis considerably. Serum carcinoembryonic antigen, a marker that is typically elevated in acquired idiopathic generalized anhidrosis, or AIGA, was normal. Thyroid function, blood glucose, and hepatitis serologies were also unremarkable, ruling out hypothyroidism, diabetes, and active infection as secondary causes. But two antibodies stood out: antinuclear antibodies and anti-SS-A/Ro antibodies, both hallmarks of Sjögren’s disease. When clinicians pressed further into her history, the patient recalled longstanding oral and conjunctival dryness and numerous treated dental caries, the classic dental consequence of diminished saliva. What had initially looked like idiopathic anhidrosis now pointed squarely toward an underlying autoimmune process.

Objective testing confirmed profound glandular failure. The Saxon test, which measures saliva accumulated over two minutes, yielded just 0.636 grams against a normal threshold of at least 2 grams. The gum test produced 3.98 milliliters in ten minutes, far below the normal minimum of 10 milliliters. Schirmer’s test, which quantifies tear production with paper strips placed under the lower eyelids, measured 3 millimeters in the right eye and 2 millimeters in the left, both well under the 5-millimeter cutoff. Salivary gland scintigraphy showed decreased uptake in the submandibular and parotid glands along with fatty infiltration of the parotids, and histological examination revealed lymphocyte and plasma cell infiltration around salivary gland ducts. The diagnosis of Sjögren’s disease was secure; the question was how it had abolished her sweating.

The answer lay in the biopsy of her anhidrotic skin, and it was not what the team expected. In Sjögren’s-related anhidrosis, two mechanisms have been described. The first is direct autoimmune inflammation of the sweat glands, so-called lymphocytic autoimmune hidradenitis, in which dense lymphocytic and plasma cell infiltration surrounds the secretory portions of eccrine glands and drives them toward atrophy. The second is autonomic dysfunction, in which the postganglionic sympathetic cholinergic nerves that command sweating fail, producing reduced sweating along dermatome patterns detectable by quantitative axon reflex testing. This patient’s skin showed neither dense inflammation nor glandular atrophy. Instead, hematoxylin and eosin staining revealed hydropic degeneration of the sweat glands, a swelling injury pattern more familiar from a completely different disease.

To characterize that injury precisely, the researchers turned to immunohistochemical markers that distinguish the two main secretory cell types of the eccrine gland. Sweat gland secretory coils are built from an inner layer of dark cells and an outer layer of clear cells, plus myoepithelial cells, forming a tightly organized two-cell-layer architecture. Carbonic anhydrase II serves as a marker of clear cells, while GCDFP15 marks dark cells. Previous work by Kenji Sano and colleagues had shown that in acquired idiopathic generalized anhidrosis, hydropic degeneration of clear cells progresses to cellular breakdown, collapse of the bilayer architecture, and ultimately glandular atrophy. In this patient, the biopsy showed exactly that pattern: aberrant carbonic anhydrase II expression in clear cells, sparse and markedly reduced GCDFP15 in dark cells, and disruption of the two-layer structure, but without the overt atrophy or inflammatory infiltration typical of Sjögren’s sweat gland disease.

This pathological ambiguity forced the clinicians into careful reasoning. The absence of inflammatory cells could mean that any earlier autoimmune attack on the glands had burned out over the ten-year disease course, leaving only residual structural damage. Alternatively, cytokines released by infiltrating immune cells might have inflicted irreversible injury on the sweat glands and their adjacent autonomic nerve fibers without leaving a visible inflammatory footprint. The team also acknowledged that they could not entirely exclude the possibility that Sjögren’s disease had become superimposed on pre-existing AIGA, a condition in which roughly 90 percent of cases occur in young men, most commonly of Asian descent, and which is associated with elevated serum CEA and cholinergic urticaria, features this patient conspicuously lacked. Weighing her demographics, her antibody profile, her normal CEA, and her clinical course, they settled on a diagnosis of generalized anhidrosis associated with Sjögren’s disease.

Treatment posed its own dilemma. No standard therapy exists for Sjögren’s-associated anhidrosis, whereas pulse corticosteroid therapy for AIGA achieves an overall response rate of approximately 73 percent, with early intervention considered particularly important. The patient received three days of intravenous methylprednisolone at 500 milligrams per day, followed by oral prednisolone starting at 25 milligrams daily and gradually tapered. The half-pulse regimen produced no significant improvement in sweating, consistent with the suspicion that her injury pattern differed from classic steroid-responsive AIGA. Yet at one-year follow-up, on a tapering dose of 5 milligrams per day, she noticed slight sweating returning to her hands and head and reported satisfaction with her treatment and heat management. That modest recovery is biologically meaningful: hydropic degeneration likely represents an edematous, milder, and potentially reversible stage of sweat gland injury, and the authors suggest that sweating function may still be recoverable if treatment begins before irreversible structural damage sets in.

The broader lesson of the case extends far beyond this single patient. Anhidrosis is more than an inconvenience; without sweating, the body’s principal cooling mechanism fails, and heat retention can escalate toward heatstroke, as this patient’s decade of summer suffering illustrates. The authors emphasize that in any patient with anhidrosis, particularly those who appear to fit the profile of acquired idiopathic generalized anhidrosis, a detailed medical history and systematic evaluation are essential to avoid overlooking underlying autoimmune disease and to enable early therapeutic intervention. A few pointed questions about dry eyes, dry mouth, and dental history transformed a mysterious ten-year condition into a diagnosable autoimmune disease, and that simple diagnostic discipline may be the most valuable finding of all.

Subject of Research: A case report of Sjögren's disease diagnosed after presentation with generalized anhidrosis, including sweat gland histopathology and steroid treatment outcomes.

Article Title: Case Report: Sjögren’s disease diagnosed following generalized anhidrosis

Article References: Shimada, Y., Ono, H., Tochigi, M., Taga, F., Shimizu, A., Kawano, M., Asahina, M., & Sano, K. (2026). Case Report: Sjögren’s disease diagnosed following generalized anhidrosis. Journal of Cutaneous Immunology and Allergy, 9, Article 17427. https://doi.org/10.3389/jcia.2026.17427

Image Credits: AI Generated

DOI: 10.3389/jcia.2026.17427

Keywords: Sjögren's disease, anhidrosis, autoimmune disease, sweat glands, acquired idiopathic generalized anhidrosis, hydropic degeneration, carbonic anhydrase II, GCDFP15, corticosteroid therapy, autonomic dysfunction, case report, dermatology