What are the treatment options for hyperhidrosis?

Treatment Options for Hyperhidrosis

Topical aluminum chloride (15% solution) is the recommended first-line treatment for axillary hyperhidrosis, with a 72% response rate in moderate-to-severe cases. 1

Treatment Algorithm Based on Affected Area

Axillary Hyperhidrosis

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

   • Apply at bedtime to completely dry skin
   • 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 per treatment
   • 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 due to safety profile 2
   • Clonidine (0.1 mg twice daily) as an alternative 2

3. Third-line: Iontophoresis

   • 20-30 minute sessions
   • Initial frequency: 3-4 times weekly
   • Maintenance: 1-2 times weekly 1
   • Can be enhanced with 1% aluminum chloride solution 3

4. Fourth-line: Botulinum toxin injections

   • Highly effective but painful and expensive
   • Requires repeat treatments every 3-6 months 2

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

   • Last resort for severe, treatment-resistant palmar hyperhidrosis
   • Not recommended for plantar hyperhidrosis due to anatomic risks 2

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1

2. Second-line: Oral medications

   • Glycopyrrolate or clonidine 2

3. Third-line: Botulinum toxin injections 2

Systemic Medications

Glycopyrrolate

• Dosing: 1-2 mg once or twice daily 2
• Administer at least one hour before or two hours after meals 4
• Side effects: dry mouth, constipation, blurred vision, urinary retention 4
• Contraindicated in patients with glaucoma, myasthenia gravis, and significant bladder outflow obstruction 4

Oxybutynin (Anticholinergic)

• Significant side effects include dry mouth, constipation, blurred vision, and cognitive effects 1
• Use with caution in elderly patients

General Recommendations

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

Assessment and Monitoring

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

Important Considerations

• Primary hyperhidrosis is bilaterally symmetric and affects specific areas such as axillae, palms, soles, and craniofacial region 1
• Secondary hyperhidrosis may be focal or generalized and is caused by an underlying medical condition or medication use 5
• Patients with hyperhidrosis have significant medical and psychosocial consequences 2
• Heat prostration (fever and heat stroke due to decreased sweating) can occur with anticholinergic drugs in high ambient temperatures 4

Common Pitfalls to Avoid

• Inadequate drying before applying aluminum chloride can reduce its effectiveness 1
• Stopping treatment too soon can lead to recurrence of symptoms 1
• Anticholinergics can cause heat prostration in hot environments 4
• Endoscopic thoracic sympathectomy can result in compensatory hyperhidrosis 1

By following this treatment algorithm based on the affected area, most patients with hyperhidrosis can achieve significant improvement in their symptoms and quality of life.