What are the treatment options for hyperhidrosis?

Treatment Options for Hyperhidrosis

Topical aluminum chloride should be used as first-line treatment for most cases of primary focal hyperhidrosis, particularly for axillary, palmar, and plantar hyperhidrosis. 1, 2

First-Line Treatments Based on Affected Area

Axillary Hyperhidrosis

• Topical aluminum chloride:
  • Most commonly used as 15-20% solution
  • Apply to dry skin at night, wash off in morning
  • Efficacy is high when used correctly

Palmar and Plantar Hyperhidrosis

• Topical aluminum chloride:
  • Apply to dry skin at night, cover with plastic wrap or occlusive gloves
  • May cause irritation; can be mitigated by applying to completely dry skin

Craniofacial Hyperhidrosis

• Topical glycopyrrolate: First-line treatment specifically for craniofacial sweating 2
• Oral anticholinergics: Consider as first-line therapy (glycopyrrolate 1-2 mg once or twice daily) 1

Second-Line Treatments

Axillary Hyperhidrosis

• Botulinum toxin injections (onabotulinumtoxinA):
  • Highly effective for 3-9 months per treatment
  • Minimal side effects for axillary treatment 2, 3

Palmar and Plantar Hyperhidrosis

• Oral medications:
  • Glycopyrrolate (1-2 mg once or twice daily) preferred over clonidine (0.1 mg twice daily) 1
  • Low cost and convenient but may have systemic anticholinergic side effects

Craniofacial Hyperhidrosis

• Botulinum toxin injections: Effective but requires expertise for proper administration 2

Third-Line Treatments

Axillary Hyperhidrosis

• Oral anticholinergic medications:
  • Glycopyrrolate or other anticholinergics
  • Limited by side effect profile (dry mouth, blurred vision, urinary retention)

Palmar and Plantar Hyperhidrosis

• Iontophoresis:
  • High efficacy but requires regular treatments
  • Can be performed at home after initial training
  • Adding anticholinergic substances to the water produces faster and longer-lasting results 3

Fourth-Line Treatments

Axillary Hyperhidrosis

• Local surgical options:
  • Curettage or liposuction of sweat glands
  • Microwave therapy (newer option) 2

Palmar and Plantar Hyperhidrosis

• Botulinum toxin injections:
  • Highly effective but painful
  • Requires anesthesia for palmar injections
  • Temporary effect (3-6 months)
  • More expensive than other options 1

Fifth-Line Treatment

Severe Refractory Cases

• Endoscopic Thoracic Sympathectomy (ETS):
  • Reserved for severe cases that haven't responded to other treatments
  • Permanent but carries risk of compensatory hyperhidrosis
  • Recommended for palmar but not plantar hyperhidrosis due to anatomic risks 1

Combination Therapies

For patients with partial response to single therapies, combination approaches can be highly effective:

• Aluminum chloride 15% in salicylic acid 2% gel base combined with botulinum toxin has shown 75-100% reduction in sweating in patients with partial response to botulinum toxin alone 4

Treatment Algorithm Based on Severity

Mild Hyperhidrosis (HDSS score 1-2)

1. Topical aluminum chloride (or glycopyrrolate for craniofacial)
2. Iontophoresis (for palms/soles)
3. Oral anticholinergics

Moderate to Severe Hyperhidrosis (HDSS score 3-4)

1. Botulinum toxin for axillary
2. Oral medications for palmar/plantar/craniofacial
3. Progress through algorithm if inadequate response

Common Pitfalls and How to Avoid Them

• Inadequate application of aluminum chloride: Must be applied to completely dry skin at night and washed off in morning
• Premature abandonment of iontophoresis: Requires consistent use (initially 3-4 times weekly, then maintenance 1-2 times weekly)
• Undertreatment with botulinum toxin: Proper dosing and complete coverage of affected area is essential
• Failure to address secondary causes: Always rule out underlying medical conditions (hyperthyroidism, pheochromocytoma, medication side effects) before treating primary hyperhidrosis 3
• Rushing to surgical options: Exhaust medical options before considering permanent surgical interventions due to risk of compensatory hyperhidrosis 5

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