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

Classification of Hyperhidrosis

Hyperhidrosis is classified into two main categories:

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

Assessment

The Hyperhidrosis Disease Severity Scale (HDSS) can be used to assess treatment effectiveness. Treatment is considered successful when the HDSS score is reduced to less than 2 1.

Treatment Algorithm by Anatomical Location

1. Axillary Hyperhidrosis

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

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

2. Second-line: Botulinum toxin injections 1, 2

   • Effective for 3-9 months
   • Requires repeated treatments

3. Third-line: Oral anticholinergics 2

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

4. Fourth-line: Microwave therapy or local surgical procedures (curettage/liposuction) 1, 3

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

2. Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride (15-20% solution) 1, 2

2. Second-line: Oral medications 2

   • Glycopyrrolate (1-2 mg once or twice daily)
   • 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
   • Can add anticholinergics to water for enhanced effect 4

4. Fourth-line: Botulinum toxin injections 1, 2

   • Painful procedure often requiring anesthesia
   • Effective but expensive

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

3. Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1, 3

2. Second-line: Oral medications 2

   • Glycopyrrolate or clonidine

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

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

Systemic Treatment Considerations

Anticholinergic Medications

• Glycopyrrolate: 1-2 mg once or twice daily 1, 2
• Oxybutynin: Use with caution due to side effects 1
• Clonidine: 0.1 mg twice daily 2

Side effects to monitor: Dry mouth, constipation, blurred vision, cognitive effects 1

Contraindications: Glaucoma, myasthenia gravis, significant bladder outflow obstruction 1

Surgical Options

Endoscopic Thoracic Sympathectomy (ETS)

• Last resort for severe, treatment-resistant cases 1, 2
• Major risk: Compensatory hyperhidrosis in other body areas 1

Local Surgical Procedures for Axillary Hyperhidrosis

• Curettage or liposuction techniques 1, 4
• Less invasive than ETS

Practical Management Tips

1. For aluminum chloride application:

   • Ensure skin is completely dry before application to maximize effectiveness
   • Apply at night and wash off in the morning
   • Use occlusive covering for enhanced effect 1

2. Lifestyle modifications:

   • Wear moisture-wicking clothing
   • Avoid extreme temperatures
   • Use cooling devices in hot environments 1

3. For iontophoresis:

   • Consistent treatment schedule is crucial for effectiveness
   • Adding anticholinergic substances to water enhances results 4

Hyperhidrosis treatment should follow a stepwise approach, starting with the least invasive options and progressing based on treatment response. The anatomical location of excessive sweating guides the specific treatment algorithm to follow.