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

Treatment Options for Hyperhidrosis (Excessive Sweating)

For hyperhidrosis management, a stepwise approach based on the affected area is recommended, starting with topical treatments before progressing to more invasive options.

Types of Hyperhidrosis

• Primary hyperhidrosis: Affects specific body areas (focal), typically begins in childhood/adolescence
• Secondary hyperhidrosis: Generalized sweating caused by underlying conditions or medications

Treatment Options by Anatomical Location

Axillary Hyperhidrosis (Underarms)

1. First-line: Topical treatments

   • Aluminum chloride (most common) 1
   • Apply to dry skin at night, wash off in morning

2. Second-line: Botulinum toxin injections

   • Effective for 3-9 months 2
   • Higher efficacy than topicals but more expensive

3. Third-line: Oral medications

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

4. Fourth-line: Local surgical options

   • Curettage or liposuction 2

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

   • Reserved for severe cases unresponsive to other treatments 1

Palmar Hyperhidrosis (Hands)

1. First-line: Topical treatments

   • Aluminum chloride solutions

2. Second-line: Oral medications

   • Glycopyrrolate preferred over clonidine due to better safety profile 1

3. Third-line: Iontophoresis

   • High efficacy but requires regular sessions
   • Can add anticholinergics to water for longer-lasting effects 2

4. Fourth-line: Botulinum toxin injections

   • Effective but painful and expensive
   • Requires repeat treatments every 3-6 months 1

5. Fifth-line: ETS

   • Consider only after failure of all other options 1

Plantar Hyperhidrosis (Feet)

1. First-line: Topical treatments

   • Aluminum chloride solutions

2. Second-line: Oral medications

   • Glycopyrrolate or clonidine 1

3. Third-line: Iontophoresis

   • Tap water iontophoresis is the method of choice 2

4. Fourth-line: Botulinum toxin injections

   • Effective but painful and requires anesthesia 1

5. ETS not recommended for plantar hyperhidrosis due to anatomical risks 1

Craniofacial Hyperhidrosis (Face/Head)

1. First-line: Oral medications

   • Glycopyrrolate or clonidine 1

2. Second-line: Topical treatments or botulinum toxin

   • Used in selected cases 1

3. Third-line: ETS

   • Only for severe cases 1

Environmental and Lifestyle Modifications

• Avoid extreme temperatures and direct sunlight 3
• Exercise during cooler parts of the day with frequent breaks 3
• Use air conditioning in hot weather 3
• Maintain adequate hydration before, during, and after physical activity 3
• Avoid alcohol consumption which can worsen heat stress 3
• Wear loose, breathable clothing 3

Medication Management

• Consider discontinuing or modifying medications that may cause hyperhidrosis 3:
  • Antidepressants
  • Decongestants
  • Immunosuppressants

Special Considerations

• Monitor core temperature during exercise when possible 3
• For prolonged activities, consider electrolyte replacement 3
• Use topical moisturizers to prevent skin fissures 3
• Be vigilant about heat exposure and always carry water 3

Common Pitfalls to Avoid

• Delayed treatment: Early intervention can prevent psychosocial consequences
• Skipping steps: Follow the treatment algorithm rather than jumping to invasive options
• Overlooking secondary causes: Rule out underlying conditions (hyperthyroidism, pheochromocytoma) 2
• Inappropriate soap use: Alkaline soaps can worsen skin conditions 3
• Underestimating psychological impact: Hyperhidrosis significantly affects quality of life 4

The treatment approach should follow this stepwise algorithm, progressing to more invasive options only after less invasive treatments have failed.