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 a disorder characterized by excessive sweating beyond what is needed for thermoregulation. It can be classified into:

• Primary (focal) hyperhidrosis: Bilaterally symmetric, affecting specific areas such as axillae, palms, soles, and craniofacial region
• Secondary hyperhidrosis: Caused by underlying medical conditions

Treatment Algorithm by Anatomical Site

Axillary Hyperhidrosis

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

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

2. Second-line: Botulinum toxin injections

   • Highly effective (92% response rate at 4 weeks compared to 33% with aluminum chloride) 2
   • Effects last 3-9 months 3

3. Third-line: Systemic anticholinergics

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

4. Fourth-line: Local surgical procedures

   • Curettage or liposuction for axillary hyperhidrosis 3

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

   • Last resort due to risk of compensatory hyperhidrosis 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)
   • Clonidine (0.1 mg twice daily) as alternative 4

3. Third-line: Iontophoresis

   • 20-30 minute sessions, 3-4 times weekly initially
   • Maintenance: 1-2 times weekly 1
   • Adding anticholinergics to water produces faster and longer-lasting results 3

4. Fourth-line: Botulinum toxin injections

   • Effective but painful and expensive
   • Requires repeated treatments every 3-6 months 4

5. Fifth-line: ETS (for palmar only)

   • Not recommended for plantar hyperhidrosis due to anatomic risks 4

Craniofacial Hyperhidrosis

1. First-line: Oral medications

   • Glycopyrrolate (1-2 mg once or twice daily)
   • Clonidine (0.1 mg twice daily) 4

2. Second-line: Topical glycopyrrolate 1

3. Third-line: Botulinum toxin injections

4. Fourth-line: ETS for severe cases 4

Systemic Medications: Important Considerations

Glycopyrrolate

• Dosing: 1-2 mg once or twice daily 4
• Contraindications: Glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, myasthenia gravis 5
• Side effects: Dry mouth, constipation, urinary retention, blurred vision 5
• Administration: At least one hour before or two hours after meals 5

Oxybutynin

• Contraindications: Glaucoma, myasthenia gravis, significant bladder outflow obstruction 6
• Side effects: Dry mouth, constipation, blurred vision, cognitive effects 1
• Caution: Use carefully in elderly, patients with hepatic or renal impairment 6
• Warning: Can cause heat prostration (fever and heat stroke due to decreased sweating) in hot environments 6

Newer Treatment Options

• Microwave therapy: Specifically for axillary hyperhidrosis 1
• Topical anticholinergics: Emerging options that may improve symptoms 7

Important Considerations and Pitfalls

• Heat sensitivity: Patients using anticholinergics must avoid hot environments due to risk of heat prostration 6, 5
• Aluminum chloride application: Must be applied to completely dry skin to be effective; stopping treatment too soon leads to symptom recurrence 1
• Assessment tool: The Hyperhidrosis Disease Severity Scale (HDSS) should be used to monitor treatment effectiveness; success is defined as reduction to HDSS score <2 1
• Psychological impact: Hyperhidrosis can cause significant psychosocial stress and decrease quality of life; effective treatment can prevent development of psychiatric comorbidities 7

For most patients with hyperhidrosis, a stepwise approach beginning with the least invasive options provides the best balance of efficacy, safety, and cost-effectiveness.