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 and Assessment

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: generalized sweating due to underlying conditions

The Hyperhidrosis Disease Severity Scale (HDSS) should be used to assess treatment effectiveness, with treatment considered successful when the HDSS score is reduced to <2 1.

Treatment Algorithm by Anatomical Location

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride 15% solution 1
2. Second-line: Botulinum toxin injections (effective for 3-9 months) 2
3. Third-line: Systemic anticholinergics (glycopyrrolate 1-2 mg once or twice daily) 2
4. Fourth-line: Local surgical procedures (curettage or liposuction) 1, 3
5. Fifth-line: Microwave therapy 1
6. Last resort: Endoscopic thoracic sympathectomy (ETS) 2

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 15% solution 1
2. Second-line: Iontophoresis (20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance) 1
3. Third-line: Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily) 2
4. Fourth-line: Botulinum toxin injections (painful but effective) 1, 2
5. Last resort for palmar only: Endoscopic thoracic sympathectomy (not recommended for plantar hyperhidrosis due to anatomic risks) 2

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1
2. Second-line: Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily or clonidine 0.1 mg twice daily) 2
3. Third-line: Botulinum toxin injections 2
4. Last resort: Endoscopic thoracic sympathectomy for severe cases 2

Medication Details

Topical Treatments

• Aluminum chloride (15% solution): Apply to completely dry skin at bedtime, wash off in the morning 1
  • Common mistake: Inadequate drying before application reduces effectiveness 1
  • In a comparative study, 33% of patients responded to aluminum chloride compared to 92% with botulinum toxin 4

Systemic Medications

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

  • Side effects: dry mouth, constipation, blurred vision, cognitive effects 1
  • Contraindicated in: glaucoma, myasthenia gravis, significant bladder outflow obstruction 1, 5
  • Should be taken 1 hour before or 2 hours after meals 5

• Clonidine (0.1 mg twice daily):

  • Alternative systemic option with different side effect profile 2

Procedural Treatments

• Iontophoresis:

  • Mechanism: Low-level electrical current delivered through water 1
  • Schedule: 20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance 1
  • Adding anticholinergic substances to the water produces faster and longer-lasting results 3

• Botulinum toxin injections:

  • Effective for 3-9 months 3
  • Requires repeated treatments 1
  • Pain during injection is a significant limitation for palmar/plantar use 2

• Surgical options:

  • Local procedures (curettage or liposuction) for axillary hyperhidrosis 1, 3
  • Endoscopic thoracic sympathectomy (ETS) as last resort due to risk of compensatory hyperhidrosis 1

Lifestyle Modifications

• 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
• Wear moisture-wicking clothing 1

Treatment Pitfalls to Avoid

1. Inadequate drying before applying aluminum chloride significantly reduces effectiveness 1
2. Stopping treatment too soon can lead to symptom recurrence 1
3. Using endoscopic thoracic sympathectomy before exhausting less invasive options 2
4. Failing to consider compensatory hyperhidrosis as a potential complication of surgical treatment 1
5. Not adjusting anticholinergic medication doses gradually to minimize side effects 5
6. Overlooking the need for maintenance therapy with iontophoresis after initial improvement 1

The Canadian Hyperhidrosis Advisory Committee recommends tailoring treatment based on both disease severity and location, with a step-up approach as needed for inadequate response 6.