What are the treatment options for hyperhidrosis?

Treatment Options for Hyperhidrosis

Topical aluminum chloride (15% solution) should be used as first-line treatment for axillary hyperhidrosis, with a 72% response rate in moderate-to-severe cases. 1

Types of Hyperhidrosis

Hyperhidrosis is classified into two main categories:

• Primary (focal) hyperhidrosis: Bilaterally symmetric, affecting specific areas such as axillae, palms, soles, and craniofacial region
• Secondary hyperhidrosis: May be focal or generalized, caused by underlying medical conditions or medications

Treatment Algorithm by Anatomical Site

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride 15% solution 1

   • Apply to completely dry skin at night
   • Wash off in the morning
   • Common side effect: skin irritation

2. Second-line: Botulinum toxin injections 1, 2

   • Effective for 3-9 months
   • Requires repeated treatments

3. Third-line: Oral anticholinergics 2

   • Glycopyrrolate (1-2 mg once or twice daily)
   • Oxybutynin (use with caution due to side effects)

4. Fourth-line: Microwave therapy or local surgical options 1, 3

   • Curettage or liposuction of sweat glands

5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) 2

   • Last resort for severe cases
   • Risk of compensatory hyperhidrosis

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 15% solution 1, 2

2. Second-line: Oral medications 2

   • Glycopyrrolate (1-2 mg once or twice daily)
   • Clonidine (0.1 mg twice daily)

3. Third-line: Iontophoresis 1, 4

   • 20-30 minute sessions
   • 3-4 times weekly initially, then 1-2 times weekly for maintenance
   • Can add anticholinergic substances to the water for enhanced effect 4

4. Fourth-line: Botulinum toxin injections 1, 5

   • Effective but painful
   • May require anesthesia for palmar injections
   • Lasts 3-6 months

5. Fifth-line (palms only): ETS 2

   • Not recommended for plantar hyperhidrosis due to anatomic risks

Craniofacial Hyperhidrosis

1. First-line: Oral medications 2

   • Glycopyrrolate or clonidine

2. Second-line: Topical glycopyrrolate 1

3. Third-line: Botulinum toxin injections 1, 3

4. Fourth-line: ETS for severe cases 2

Assessment and Monitoring

The Hyperhidrosis Disease Severity Scale (HDSS) can be used to assess treatment effectiveness:

• Treatment is considered successful when HDSS score is reduced to <2 1
• This scale measures the tolerability of sweating and its impact on quality of life 3

Important Considerations and Precautions

• For aluminum chloride application: Ensure skin is completely dry before application to maximize effectiveness 1
• For anticholinergic medications: Monitor for side effects including dry mouth, constipation, blurred vision, and cognitive effects 1
• Contraindications for anticholinergics: Glaucoma, myasthenia gravis, and significant bladder outflow obstruction 1
• For ETS: Counsel patients about the risk of compensatory hyperhidrosis, which can be worse than the original condition 6
• For iontophoresis: Requires consistent maintenance treatments to sustain benefits 4

Non-Pharmacological Management

• Wear moisture-wicking clothing 1
• Avoid extreme temperatures and outdoor activities during hot periods 1
• Use cooling devices in hot environments 1
• Apply cold water or packs regularly to help cool the skin 1

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