What are the treatment options for underarm hyperhidrosis in men?

Treatment Options for Underarm Hyperhidrosis in Men

Aluminum chloride hexahydrate (15-20%) is the first-line treatment for axillary hyperhidrosis due to its proven efficacy, safety profile, and accessibility. 1

First-Line Treatment

• Topical antiperspirants
  • 15-20% aluminum chloride hexahydrate applied nightly to completely dry skin
  • Apply to dry axillae before bedtime and wash off in the morning
  • May cause skin irritation in some patients
  • Use of barrier preparations and moisturizers can help reduce irritation

Second-Line Treatment

• Botulinum toxin A injections
  • Highly effective for axillary hyperhidrosis with significant reduction in sweat production
  • Effects last 6-8 months before requiring repeat treatment
  • Studies show reduction from baseline sweat production of 192 mg/min to 24 mg/min two weeks after injection 2
  • Well-tolerated with 98% of patients recommending this therapy to others 2
  • Limitations include cost and need for repeat injections

Third-Line Treatment

• Systemic oral medications
  • Anticholinergics (glycopyrrolate 1-2 mg once or twice daily)
  • Effectiveness limited by systemic side effects at doses required to control sweating 3
  • Side effects include dry mouth, blurred vision, urinary retention, and constipation
  • Should be used when topical treatments and botulinum toxin fail

Fourth-Line Treatment

• Local surgical options
  • Curettage or liposuction of axillary sweat glands
  • Effective but may cause unsightly scarring 4
  • Should only be considered after failure of less invasive methods

Fifth-Line Treatment

• Endoscopic thoracic sympathectomy (ETS)
  • Last resort for severe, treatment-resistant cases
  • Permanent solution but carries significant risks
  • Complications include compensatory hyperhidrosis, Horner syndrome, and neuralgia 4
  • Some patients find these complications worse than the original condition

Adjunctive Measures

• Lifestyle modifications
  • Wear loose, breathable clothing made of natural fibers
  • Avoid triggers such as extreme temperatures and hot environments
  • Use neutral pH, fragrance-free hypoallergenic soaps 1
  • Regular bathing with warm water followed by moisturizers

Treatment Algorithm

1. Start with aluminum chloride 15-20% applied nightly to dry axillae
2. If inadequate response after 1 month, proceed to botulinum toxin A injections
3. If botulinum toxin is ineffective or not feasible, trial oral anticholinergics
4. Consider surgical options only after failure of all medical therapies

Common Pitfalls and Caveats

• Ensure axillae are completely dry before applying aluminum chloride to prevent irritation
• Botulinum toxin requires proper injection technique to maximize efficacy and minimize side effects
• Patients should be warned about compensatory hyperhidrosis that may occur with surgical treatments
• Iontophoresis, while effective for palmar and plantar hyperhidrosis, has limited efficacy for axillary hyperhidrosis

The treatment approach should follow a stepwise progression from least to most invasive options, with careful consideration of efficacy, side effects, cost, and patient preference at each stage.