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

Understanding Hyperhidrosis

Hyperhidrosis is excessive sweating beyond what is needed for thermoregulation and environmental conditions. It is classified into two main categories:

• Primary (focal) hyperhidrosis: Bilaterally symmetric, affecting specific areas with high eccrine density (axillae, palms, soles, craniofacial region)
• Secondary hyperhidrosis: Caused by underlying medical conditions or medications

Treatment Algorithm by Anatomical Site

Axillary Hyperhidrosis

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

   • Apply to dry skin at night
   • Wash off in the morning
   • Common mistake: Inadequate drying before application reduces effectiveness 1

2. Second-line: Botulinum toxin injections

   • Effective for 3-9 months
   • High efficacy but requires repeated treatments 1

3. Third-line: Oral anticholinergics

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

4. Fourth-line: Microwave therapy (newer option specifically for axillary hyperhidrosis) 1

5. Fifth-line: Local surgical procedures (curettage or liposuction) 1

Palmar and Plantar Hyperhidrosis

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

2. Second-line: Oral medications

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

3. Third-line: Iontophoresis

   • Low-level electrical current delivered through water
   • 20-30 minute sessions, 3-4 times weekly initially
   • Maintenance: 1-2 times weekly 1

4. Fourth-line: Botulinum toxin injections

   • Painful procedure often requiring anesthesia
   • Effective for 3-6 months 2

5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) for palmar hyperhidrosis only

   • Not recommended for plantar hyperhidrosis due to anatomic risks 2

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1, 3

2. Second-line: Oral medications

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

3. Third-line: Botulinum toxin injections 3

4. Fourth-line: Endoscopic thoracic sympathectomy (ETS) for severe cases 2

Medication Details and Considerations

Glycopyrrolate

• Dosing: 1-2 mg once or twice daily 2
• Contraindications: Glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, myasthenia gravis 4
• Side effects: Dry mouth, constipation, blurred vision, urinary retention 4
• Administration: Give at least one hour before or two hours after meals (high fat food reduces bioavailability) 4

Aluminum Chloride

• Application: Apply to completely dry skin at night, wash off in morning
• Efficacy: 72% response rate in moderate-to-severe cases 1
• Enhancement: Can be combined with botulinum toxin for improved results in partial responders 5

Monitoring Treatment Effectiveness

The Hyperhidrosis Disease Severity Scale (HDSS) should be used to assess treatment effectiveness. Treatment is considered successful when the HDSS score is reduced to less than 2 1.

Important Considerations and Pitfalls

• Heat sensitivity: Patients using anticholinergics should avoid extreme temperatures and outdoor activities during hot periods due to risk of heat prostration 1, 4
• Inadequate drying: Ensure skin is completely dry before applying aluminum chloride to maximize effectiveness 1
• Premature discontinuation: Stopping treatment too soon can lead to symptom recurrence 1
• Driving and machinery operation: Glycopyrrolate may cause drowsiness or blurred vision, affecting ability to operate machinery or drive 4
• Combination therapy: For patients with partial response to botulinum toxin, adding aluminum chloride can significantly improve results 5

Lifestyle Modifications

• Wear moisture-wicking clothing
• Apply cold water or packs regularly to help cool the skin
• Use cooling devices in hot environments 1

By following this treatment algorithm and considering individual patient factors, hyperhidrosis can be effectively managed in most patients, significantly improving quality of life.