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

Treatment Options for Hyperhidrosis (Excessive Sweating)

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 a disorder characterized by excessive sweating beyond what is needed for thermoregulation. It affects approximately 3% of the population and can be classified into two main categories:

• Primary (focal) hyperhidrosis: Bilaterally symmetric, affecting specific areas such as axillae, palms, soles, and craniofacial region
• Secondary hyperhidrosis: Generalized sweating due to underlying conditions

Treatment Algorithm by Anatomical Location

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 1, 2

   • Glycopyrrolate (1-2 mg once or twice daily)
   • Oxybutynin (watch for side effects)

4. Fourth-line: Local surgical procedures 1, 2

   • Curettage or liposuction

5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) 1, 2

   • Last resort for severe cases
   • Risk of compensatory hyperhidrosis

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 1, 2

2. Second-line: Oral medications 1, 2

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

3. Third-line: Iontophoresis 1, 2

   • 20-30 minute sessions
   • 3-4 times weekly initially, then 1-2 times weekly for maintenance
   • High efficacy but requires dedicated equipment

4. Fourth-line: Botulinum toxin injections 1, 2

   • Painful for palms/soles
   • May require anesthesia

5. Fifth-line: ETS (for palmar only, not recommended for plantar) 1, 2

Craniofacial Hyperhidrosis

1. First-line: Oral medications 1, 2

   • Glycopyrrolate or clonidine

2. Second-line: Topical glycopyrrolate 1

3. Third-line: Botulinum toxin injections 1, 2

4. Fourth-line: ETS (for severe cases only) 1, 2

Newer Treatment Options

• Microwave therapy: Specifically for axillary hyperhidrosis 1
• Topical anticholinergics: Newer formulations with improved efficacy 3

Managing Side Effects and Practical Considerations

For Topical Aluminum Chloride

• Ensure skin is completely dry before application
• Apply at night when sweating is minimal
• Use plastic wrap to enhance penetration if needed
• If irritation occurs, reduce frequency or concentration

For Anticholinergic Medications

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

For Iontophoresis

• Can add anticholinergic substances to the water for enhanced effect 4
• Maintain consistent treatment schedule for best results

Lifestyle Modifications

• Avoid extreme temperatures and outdoor activities during hot periods 5, 1
• Wear moisture-wicking clothing 1
• Use cooling devices in hot environments 5, 1
• Apply cold water or packs regularly to help cool the skin 5, 1

Treatment Assessment

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

Common Pitfalls to Avoid

• Inadequate drying before applying aluminum chloride reduces its effectiveness 1
• Stopping treatment too soon can lead to symptom recurrence 1
• Failing to try conservative options before pursuing invasive treatments 2, 4
• Not addressing the significant psychosocial impact of hyperhidrosis 3