Treatment Options for Hyperhidrosis
Topical antiperspirants containing aluminum chloride should be used as first-line treatment for most forms of focal hyperhidrosis, particularly axillary hyperhidrosis, due to their safety, efficacy, and accessibility.
Diagnostic Approach
- Hyperhidrosis is characterized by excessive sweating beyond thermoregulatory needs
- Two main classifications:
- Primary (focal) hyperhidrosis: Most common, affecting specific areas like axillae, palms, soles, and craniofacial region
- Secondary hyperhidrosis: Generalized sweating due to underlying medical conditions or medications
Treatment Algorithm Based on Anatomical Location
Axillary Hyperhidrosis
- First-line: Topical antiperspirants (aluminum chloride 20-25%) 1
- Second-line: Botulinum toxin A injections 1
- Third-line: Oral anticholinergics (glycopyrrolate 1-2mg once or twice daily) 1, 2
- Fourth-line: Local surgical options (curettage, liposuction) 3
- Fifth-line: Endoscopic thoracic sympathectomy (ETS) 1
Palmar Hyperhidrosis
- First-line: Topical antiperspirants (aluminum chloride) 1
- Second-line: Oral medications (glycopyrrolate preferred over clonidine) 1
- Third-line: Tap water iontophoresis 1, 3
- Fourth-line: Botulinum toxin injections 1
- Fifth-line: Endoscopic thoracic sympathectomy (for severe cases) 1
Plantar Hyperhidrosis
- First-line: Topical antiperspirants (aluminum chloride) 1
- Second-line: Oral medications (glycopyrrolate preferred) 1
- Third-line: Tap water iontophoresis 1, 3
- Fourth-line: Botulinum toxin injections 1
- ETS not recommended for plantar hyperhidrosis due to anatomical risks 1
Craniofacial Hyperhidrosis
- First-line: Oral medications (glycopyrrolate or clonidine) 1
- Second-line: Topical antiperspirants (used cautiously) 1
- Third-line: Botulinum toxin injections 1
- Fourth-line: ETS (only for severe cases) 1
Detailed Treatment Options
Topical Treatments
- Aluminum chloride (20-25%): Apply to dry skin at night, wash off in morning
- Most effective for axillary hyperhidrosis 3
- Common side effect: skin irritation
- Practical tip: Use plastic wrap occlusion to enhance efficacy for palmar/plantar hyperhidrosis
Iontophoresis
- Particularly effective for palmoplantar hyperhidrosis 3
- Mechanism: Tap water ionization using mild electrical current
- Treatment regimen: 3-4 sessions per week initially, then maintenance 1-2 times weekly
- Adding anticholinergics to water enhances efficacy and duration 3
Botulinum Toxin Injections
- Highly effective for axillary, palmar, and plantar hyperhidrosis 4
- Duration: 3-9 months of relief 3
- Limitations: Cost, pain during injection (especially for palms/soles), need for repeated treatments
Oral Medications
- Glycopyrrolate (1-2mg once or twice daily): First-choice systemic therapy 1, 2
- Clonidine (0.1mg twice daily): Alternative option 1
- Side effects: Dry mouth, blurred vision, urinary retention, constipation
- Caution in elderly patients due to anticholinergic side effects
Surgical Options
- Local procedures for axillary hyperhidrosis:
- Curettage and liposuction 3
- Endoscopic Thoracic Sympathectomy (ETS):
- Last resort for severe, refractory cases
- Permanent but high risk of compensatory hyperhidrosis 1
Special Considerations
Lifestyle Modifications
- Avoid triggers: extreme temperatures, tight clothing, spicy foods
- Use breathable fabrics (cotton)
- Regular bathing with mild cleansers
- Avoid alkaline soaps that can disrupt skin barrier function 5
Psychological Impact
- Hyperhidrosis significantly impacts quality of life 4
- Consider screening for anxiety or depression in severely affected patients
- Some patients may have excoriation disorder (skin picking) that worsens skin lesions 5
Treatment Selection Factors
- Severity of hyperhidrosis
- Anatomical location
- Patient preference and convenience
- Cost considerations
- Previous treatment responses
- Potential side effects
By following this algorithmic approach to hyperhidrosis treatment, most patients can achieve significant symptom improvement and better quality of life.