What are the treatment options and diagnosis criteria for hyperhidrosis?

Management of Hyperhidrosis: Diagnosis and Treatment

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

Diagnosis Criteria for Hyperhidrosis

Hyperhidrosis is classified into two main categories:

1. Primary (Focal) Hyperhidrosis:

   • Bilaterally symmetric sweating
   • Affects specific areas: axillae, palms, soles, and craniofacial region
   • Onset typically in childhood or adolescence
   • No underlying medical cause
   • Often has family history
   • Sweating stops during sleep

2. Secondary Hyperhidrosis:

   • May be focal or generalized
   • Caused by underlying medical conditions or medications
   • May persist during sleep

Assessment Tool

The Hyperhidrosis Disease Severity Scale (HDSS) is recommended to assess severity and treatment effectiveness:

• Score 1: Not noticeable, no interference with daily activities
• Score 2: Tolerable but sometimes interferes with daily activities
• Score 3: Barely tolerable and frequently interferes with daily activities
• Score 4: Intolerable and always interferes with daily activities

Treatment is considered successful when HDSS score is reduced to <2 1

Treatment Algorithm Based on Location and Severity

Axillary Hyperhidrosis

1. Mild (HDSS 2):

   • First-line: Topical aluminum chloride 15% solution 1
   • Second-line: Botulinum toxin A injections 1, 2
   • Third-line: Oral anticholinergics (glycopyrrolate 1-2mg once/twice daily) 3
   • Fourth-line: Microwave therapy or local surgical procedures 1, 2

2. Severe (HDSS 3-4):

   • First-line: Botulinum toxin A injections or topical aluminum chloride 1, 4
   • Second-line: Oral anticholinergics 3
   • Third-line: Microwave therapy 1
   • Fourth-line: Local surgical procedures (curettage/liposuction) 1
   • Last resort: Endoscopic thoracic sympathectomy (ETS) 1, 2

Palmar and Plantar Hyperhidrosis

1. Mild (HDSS 2):

   • First-line: Topical aluminum chloride 15% solution 1
   • Second-line: Iontophoresis or botulinum toxin A 1, 4

2. Severe (HDSS 3-4):

   • First-line: Botulinum toxin A, topical aluminum chloride, or iontophoresis 1, 4
   • Second-line: Oral anticholinergics (glycopyrrolate preferred over clonidine) 3
   • Last resort: ETS (for palmar only, not recommended for plantar) 3

Craniofacial Hyperhidrosis

• First-line: Topical glycopyrrolate, oral anticholinergics, or botulinum toxin A 1, 2, 3
• Second-line: ETS for severe cases unresponsive to other treatments 3

Treatment Details and Administration

Topical Treatments

• Aluminum chloride (15% solution):

  • Apply to completely dry skin at night
  • Wash off in the morning
  • Common mistake: Inadequate drying before application reduces effectiveness 1
  • Initially apply daily, then reduce to 1-2 times weekly for maintenance

• Topical glycopyrrolate:

  • Preferred for craniofacial hyperhidrosis 1
  • Apply to affected areas once daily

Iontophoresis

• Mechanism: Low-level electrical current delivered through water
• Frequency: 20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance
• Particularly effective for palmar and plantar hyperhidrosis 1

Botulinum Toxin Injections

• Highly effective for all types of focal hyperhidrosis
• Duration: Effects last 3-9 months, requiring repeat treatments
• Limitation: Can be painful, particularly for palmar and plantar injections 1

Systemic Medications

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

  • Preferred anticholinergic due to better side effect profile
  • Side effects: Dry mouth, constipation, blurred vision

• Clonidine (0.1 mg twice daily):

  • Alternative for patients who cannot tolerate anticholinergics
  • Side effects: Hypotension, dizziness, sedation

• Oxybutynin:

  • Significant side effects limit use
  • Contraindicated in patients with glaucoma, myasthenia gravis, and significant bladder outflow obstruction 1

Surgical Options

• Microwave therapy:

  • Newer option specifically for axillary hyperhidrosis 1
  • Non-invasive procedure that destroys sweat glands

• Local procedures (curettage or liposuction):

  • For axillary hyperhidrosis 1
  • Removes or destroys sweat glands

• Endoscopic thoracic sympathectomy (ETS):

  • Last resort for severe, treatment-resistant cases
  • Major complication: Compensatory hyperhidrosis (increased sweating in other body areas) 1, 5
  • Not recommended for plantar hyperhidrosis due to anatomic risks 3

Practical Management Tips

• Patients should wear moisture-wicking clothing
• Avoid extreme temperatures and outdoor activities during hot periods
• Use cooling devices in hot environments
• Apply cold water or packs regularly to help cool the skin 1
• Maintain treatment even after improvement to prevent recurrence 1

By following this evidence-based approach to diagnosis and treatment, most patients with hyperhidrosis can achieve significant improvement in their symptoms and quality of life.