What are the indications for prescribing treatments for hyperhidrosis?

Treatment Indications for Hyperhidrosis

Topical treatments like aluminum chloride should be prescribed as first-line therapy for most forms of focal hyperhidrosis, followed by more advanced therapies based on the specific affected area and response to initial treatment. 1

Classification and Assessment

Hyperhidrosis is classified into two main types:

• Primary hyperhidrosis: Bilaterally symmetric, focal excessive sweating
• Secondary hyperhidrosis: Caused by underlying medical conditions or medications

Assessment should utilize the Hyperhidrosis Disease Severity Scale to guide treatment decisions 1.

Treatment Algorithm by Anatomical Location

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride

   • Apply to completely dry skin at night
   • Wash off in the morning
   • Most effective when applied to completely dry skin

2. Second-line: Botulinum toxin injections

   • Highly effective with effects lasting 3-9 months 1, 2
   • Requires repeated treatments

3. Third-line: Oral anticholinergics

   • Glycopyrrolate 1-2 mg once or twice daily
   • Monitor for side effects (dry mouth, blurred vision, urinary retention)

4. Fourth-line: Local surgical options (curettage, liposuction)

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

   • Reserved for severe, treatment-resistant cases 3

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride

2. Second-line: Oral medications

   • Glycopyrrolate 1-2 mg once or twice daily preferred over clonidine 0.1 mg twice daily 3
   • Low cost, convenient, reasonable efficacy

3. Third-line: Iontophoresis

   • Particularly effective for palmoplantar hyperhidrosis 1
   • Can be enhanced by adding anticholinergic substances to the water 2
   • High efficacy but higher initial cost and inconvenience

4. Fourth-line: Botulinum toxin injections

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

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

   • Not recommended for plantar hyperhidrosis due to anatomic risks 3

Craniofacial Hyperhidrosis

1. First-line: Oral medications

   • Glycopyrrolate or clonidine 3

2. Second-line: Topical aluminum chloride or botulinum toxin injections

3. Third-line: ETS for severe cases

Common Pitfalls and How to Avoid Them

1. Improper application of aluminum chloride

   • Ensure skin is completely dry before application
   • Apply at night when sweating is minimal
   • Cover with plastic wrap for enhanced effect

2. Inadequate dosing of oral medications

   • Start with low doses and titrate up based on response
   • Monitor for anticholinergic side effects

3. Underestimating quality of life impact

   • Hyperhidrosis causes significant psychosocial stress and emotional distress 1
   • Aggressive treatment is often warranted to improve quality of life

4. Failing to address underlying causes in secondary hyperhidrosis

   • Rule out hyperthyroidism, pheochromocytoma, and medication effects 2
   • Treating the underlying condition may resolve hyperhidrosis

5. Premature progression to invasive treatments

   • Exhaust conservative options before considering surgical interventions
   • Surgical treatments carry risks of permanent side effects 4

Adjunctive Measures

• Lifestyle modifications: Avoid extreme temperatures, wear appropriate clothing, use cooling devices 1
• Regular water spraying, bathing, or showering to help cool the skin 1
• Address psychological impact as part of comprehensive management 1

By following this structured approach to treating hyperhidrosis based on anatomical location and severity, clinicians can significantly improve patients' quality of life while minimizing side effects and complications.