Treatment Options for Hyperhidrosis
The first-line treatment for hyperhidrosis is topical aluminum chloride, which should be applied to affected areas as it effectively reduces excessive sweating with minimal systemic effects. 1
Overview of Treatment Options
Hyperhidrosis is characterized by excessive sweating beyond what is needed for thermoregulation, affecting approximately 3% of the population and causing significant medical and psychosocial consequences. Treatment options should follow a stepwise approach based on the affected anatomical site.
Anatomical Site-Specific Treatment Algorithms
Axillary Hyperhidrosis
- First-line: Topical aluminum chloride (typically 20% concentration)
- Second-line: Botulinum toxin injections
- Third-line: Oral anticholinergic medications (glycopyrrolate 1-2mg once or twice daily)
- Fourth-line: Local surgical options
- Fifth-line: Endoscopic thoracic sympathectomy (ETS)
Palmoplantar Hyperhidrosis
- First-line: Topical aluminum chloride
- Second-line: Oral medications
- Glycopyrrolate 1-2mg once or twice daily (preferred)
- Clonidine 0.1mg twice daily (alternative)
- Third-line: Iontophoresis
- Fourth-line: Botulinum toxin injections
- Fifth-line: ETS (for palmar only, not recommended for plantar)
Craniofacial Hyperhidrosis
- First-line: Oral medications (glycopyrrolate or clonidine)
- Second-line: Topical aluminum chloride
- Third-line: Botulinum toxin injections
- Fourth-line: ETS (for severe cases only)
Detailed Treatment Options
Topical Treatments
- Aluminum chloride (20%): Apply to dry skin at night, wash off in morning
- Efficacy: 33% achieve significant reduction in sweating at 4 weeks 2
- Common side effects: Skin irritation, burning sensation
Iontophoresis
- Uses electrical current to deliver tap water or anticholinergic medications through skin
- Requires regular sessions (initially 3-4 times weekly, then maintenance 1-2 times weekly)
- High efficacy but requires specialized equipment and time commitment
Botulinum Toxin Injections
- Highly effective: 92% response rate at 4 weeks 2
- Duration: 3-6 months before retreatment needed
- Limitations: Pain during injection, cost, need for repeated treatments
Oral Medications
- Glycopyrrolate: Anticholinergic, 1-2mg once or twice daily
- Clonidine: Alpha-2 adrenergic agonist, 0.1mg twice daily
- Side effects: Dry mouth, blurred vision, urinary retention, constipation
Surgical Options
- Endoscopic Thoracic Sympathectomy (ETS)
- Reserved for severe, treatment-resistant cases
- Permanent solution but risk of compensatory hyperhidrosis
- Not recommended for plantar hyperhidrosis due to anatomic risks
Important Considerations
- Compensatory hyperhidrosis: A common side effect of ETS where sweating increases in untreated areas
- Treatment combinations: Often needed for optimal control
- Quality of life impact: Should guide treatment aggressiveness
- Maintenance therapy: Often required even after successful initial treatment
The most recent evidence suggests that a stepwise approach starting with the least invasive options provides the best balance of efficacy and safety 3. For patients with severe, treatment-resistant hyperhidrosis, combining multiple treatment modalities may be necessary to achieve adequate symptom control.