What are good initial treatment options for hyperhidrosis?

Treatment Options for Hyperhidrosis

Topical aluminum chloride (15% solution) is the first-line treatment for axillary hyperhidrosis, with a 72% response rate in moderate-to-severe cases. 1 For other forms of hyperhidrosis, treatment should be tailored to the specific affected area.

Treatment Algorithm Based on Affected Area

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride (15% solution)
2. Second-line: Botulinum toxin injections
3. Third-line: Oral anticholinergics (glycopyrrolate or oxybutynin)
4. Fourth-line: Local procedures (microwave therapy, curettage, liposuction)
5. Fifth-line: Endoscopic thoracic sympathectomy (ETS)

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride
2. Second-line: Oral glycopyrrolate (1-2 mg once or twice daily) or clonidine (0.1 mg twice daily) 2
3. Third-line: Iontophoresis (20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance)
4. Fourth-line: Botulinum toxin injections (effective but painful and requires repeated treatments every 3-9 months)
5. Fifth-line: ETS (for palmar only, not recommended for plantar due to anatomic risks) 2

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1
2. Second-line: Oral medications (glycopyrrolate or clonidine)
3. Third-line: Botulinum toxin injections
4. Fourth-line: ETS (for severe cases only)

Medication Details

Topical Treatments

• Aluminum chloride (15-20%): Apply at night to dry skin, wash off in morning. Most effective when skin is completely dry before application.
• Topical glycopyrrolate: Preferred for craniofacial hyperhidrosis.

Systemic Medications

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

  • Contraindicated in patients with glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, myasthenia gravis 3
  • Side effects: dry mouth, constipation, blurred vision, urinary retention 3

• Oxybutynin: Starting at low doses and titrating up

  • Side effects: dry mouth, constipation, blurred vision, cognitive effects 1
  • Contraindicated in patients with glaucoma, myasthenia gravis, and significant bladder outflow obstruction 1

• Clonidine: 0.1 mg twice daily 2

Non-Pharmacological Interventions

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
• Advantages: Non-invasive, can be done at home with proper equipment

Botulinum Toxin Injections

• Mechanism: Blocks release of acetylcholine at nerve endings
• Duration: Effects last 3-9 months
• Best for: Axillary hyperhidrosis (second-line), palmar/plantar (fourth-line)
• Disadvantages: Pain during injection (especially for palms/soles), need for repeated treatments

Microwave Therapy

• Newer option specifically for axillary hyperhidrosis
• Permanently destroys sweat glands

Practical Management Tips

• Avoid extreme temperatures and outdoor activities during hot periods 4
• Use cooling devices in hot environments (air conditioning, fans)
• Apply cold water or packs regularly to help cool the skin 4
• Wear appropriate moisture-wicking clothing
• Use the Hyperhidrosis Disease Severity Scale (HDSS) to assess treatment effectiveness; treatment is considered successful when HDSS score is reduced to <2 1

Common Pitfalls to Avoid

1. Inadequate drying before applying aluminum chloride: The skin must be completely dry for maximum effectiveness.
2. Stopping treatment too soon: Many treatments require maintenance therapy.
3. Overlooking secondary causes: Always rule out underlying medical conditions (hyperthyroidism, pheochromocytoma, medications) before treating as primary hyperhidrosis.
4. Rushing to invasive procedures: Exhaust conservative options before considering surgical interventions.
5. Ignoring psychological impact: Hyperhidrosis significantly impacts quality of life and may require addressing psychological distress.

By following this systematic approach based on the affected area, most patients with hyperhidrosis can achieve significant improvement in their symptoms and quality of life.