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 excessive sweating beyond what is needed for thermoregulation. It is classified into two main categories:

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

Treatment Algorithm by Anatomical Site

Axillary Hyperhidrosis

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

   • Apply to dry skin at night
   • Wash off in the morning
   • Common side effect: skin irritation

2. Second-line: Botulinum toxin injections 1

   • Effective for 3-9 months
   • Requires repeated treatments

3. Third-line: Oral anticholinergics 1, 2

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

4. Fourth-line: Local procedures (curettage or liposuction) 1, 3

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

   • Last resort for severe, treatment-resistant cases
   • Risk of compensatory hyperhidrosis

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 1, 4

2. Second-line: Oral medications 2

   • Glycopyrrolate (1-2 mg once or twice daily)
   • Alternative: clonidine (0.1 mg twice daily)

3. Third-line: Iontophoresis 1, 4

   • 20-30 minute sessions
   • 3-4 times weekly initially, then 1-2 times weekly for maintenance

4. Fourth-line: Botulinum toxin injections 1

   • Highly effective but painful
   • May require anesthesia for palmar injections

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

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1, 4

2. Second-line: Oral medications 2

   • Glycopyrrolate or clonidine

3. Third-line: Botulinum toxin injections 1, 4

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

Systemic Medications

Glycopyrrolate

• Dosage: 1-2 mg once or twice daily 2
• Side effects: dry mouth, constipation, blurred vision, urinary retention 5
• Contraindicated in glaucoma, myasthenia gravis, significant bladder outflow obstruction 5

Oxybutynin

• Common side effects: dry mouth, constipation, blurred vision, cognitive effects 6
• Use with caution in elderly, hepatic/renal impairment, and patients with myasthenia gravis 6
• Risk of heat prostration due to decreased sweating in hot environments 6

Assessment and Monitoring

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

Important Considerations and Pitfalls

• Inadequate drying before applying aluminum chloride: Ensure skin is completely dry before application to maximize effectiveness 1
• Stopping treatment too soon: Continued maintenance therapy is often needed to prevent recurrence 1
• Heat sensitivity: Patients using anticholinergics should avoid extreme temperatures and outdoor activities during hot periods to prevent heat prostration 1, 6
• Clothing choice: Recommend moisture-wicking clothing to help manage symptoms 1
• Medication interactions: Anticholinergics may interact with other medications that produce similar side effects 5, 6
• Compensatory hyperhidrosis: A significant risk after ETS surgery, where sweating increases in untreated areas 2

By following this structured approach to hyperhidrosis management, most patients can achieve significant improvement in their symptoms and quality of life.