What are the treatment options for hyperhidrosis (excessive sweating)?

Treatment Options for Hyperhidrosis (Excessive Sweating)

Topical aluminum chloride should be used as first-line treatment for most forms of primary focal hyperhidrosis, particularly for axillary hyperhidrosis, with 15% aluminum chloride solutions showing 72% effectiveness in reducing symptom severity.

Types of Hyperhidrosis

Hyperhidrosis is classified into two main categories:

• Primary (focal) hyperhidrosis: Bilaterally symmetric, affecting specific areas such as:

  • Axillae (armpits)
  • Palms
  • Soles
  • Craniofacial region

• Secondary hyperhidrosis: May be focal or generalized, caused by underlying medical conditions or medications

Treatment Algorithm by Anatomical Location

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride (15% solution in salicylic acid gel base) 1

   • Apply nightly for first week, then twice weekly as tolerated
   • 72% of patients achieve significant reduction in symptoms

2. Second-line: Botulinum toxin injections (onabotulinumtoxinA) 2, 3

3. Third-line: Oral anticholinergics (glycopyrrolate 1-2 mg once/twice daily) 2

4. Fourth-line: Local surgical options (curettage or liposuction) 4

5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) - reserved for severe cases unresponsive to other treatments 2

6. Newer option: Microwave therapy 3

Palmar Hyperhidrosis

1. First-line: Topical aluminum chloride 2

2. Second-line: Oral medications 2

   • Glycopyrrolate 1-2 mg once/twice daily (preferred)
   • Clonidine 0.1 mg twice daily (alternative)

3. Third-line: Iontophoresis (tap water) 2, 4

   • Can add anticholinergic substances to water for enhanced effect

4. Fourth-line: Botulinum toxin injections 2

   • Note: Painful procedure often requiring anesthesia

5. Fifth-line: Endoscopic thoracic sympathectomy 2

Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 2

2. Second-line: Oral medications (glycopyrrolate or clonidine) 2

3. Third-line: Iontophoresis 2, 4

4. Fourth-line: Botulinum toxin injections 2

   • ETS not recommended for plantar hyperhidrosis due to anatomic risks 2

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 3

2. Second-line: Oral medications (glycopyrrolate or clonidine) 2

3. Third-line: Botulinum toxin injections 2, 3

4. Fourth-line: ETS (for severe cases only) 2

Medication Details and Administration

Topical Treatments

• Aluminum chloride (15% solution):

  • Application: Apply to completely dry skin at bedtime, wash off in morning
  • Frequency: Daily initially, then 1-2 times weekly for maintenance
  • Evidence: 72% response rate in moderate-to-severe axillary hyperhidrosis 1
  • Caution: May cause skin irritation; applying petroleum jelly to surrounding skin can reduce irritation

• Glycopyrrolate (topical):

  • Preferred for craniofacial hyperhidrosis 3

Oral Medications

• Oxybutynin (anticholinergic):

  • Caution: Can cause significant side effects including dry mouth, constipation, blurred vision, and cognitive effects 5
  • Contraindicated in patients with glaucoma, myasthenia gravis, and significant bladder outflow obstruction 5
  • Monitor for heat prostration in hot environments due to decreased sweating 5

• Glycopyrrolate: 1-2 mg once or twice daily 2

• Clonidine: 0.1 mg twice daily 2

Procedural Treatments

• Iontophoresis:

  • Mechanism: Low-level electrical current delivered through water
  • Frequency: 20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance
  • Best for: Palmar and plantar hyperhidrosis 2, 4

• Botulinum Toxin Injections:

  • Duration: Effects last 3-9 months 4
  • Advantage: Highly effective for axillary hyperhidrosis
  • Disadvantage: Painful for palmar/plantar application, expensive, requires repeat treatments

• Microwave Therapy:

  • Newer option specifically for axillary hyperhidrosis 3

• Surgical Options:

  • Local procedures (for axillary): Curettage or liposuction 4
  • Endoscopic thoracic sympathectomy: Last resort for severe, treatment-resistant cases 2, 4

Special Considerations

Environmental Management

• Avoid extreme temperatures and outdoor activities during hot periods 6
• Use cooling devices (air conditioning, fans) in hot environments 6
• Regular application of cold water or packs can help cool the skin 6
• Wear appropriate clothing that wicks moisture away from the body

Monitoring Treatment Response

• Use the Hyperhidrosis Disease Severity Scale (HDSS) to assess treatment effectiveness 3
• Consider treatment successful when HDSS score is reduced to <2 1

Potential Pitfalls

• Compensatory hyperhidrosis can occur after ETS surgery
• Systemic anticholinergics may have significant side effects limiting their use 4
• Topical treatments require consistent application on completely dry skin for effectiveness
• Botulinum toxin injections, while effective, require repeated treatments every 3-9 months 4

By following this structured approach to treatment, most patients with hyperhidrosis can achieve significant improvement in symptoms and quality of life.