What are the treatment options for primary hyperhidrosis (excessive sweating)?

Treatment Options for Primary Hyperhidrosis

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

Classification and Diagnosis

Primary hyperhidrosis is characterized by:

• Bilaterally symmetric, focal excessive sweating
• Commonly affects axillae, palms, soles, and craniofacial region
• Not caused by underlying medical conditions
• Often has a genetic component

Secondary hyperhidrosis may be focal or generalized and is caused by underlying conditions or medications.

The Hyperhidrosis Disease Severity Scale (HDSS) should be used to assess severity and treatment effectiveness, with successful treatment defined as reduction to HDSS score <2 1.

Treatment Algorithm by Anatomical Site

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride (15% solution) 1
2. Second-line: Botulinum toxin injections (onabotulinumtoxinA)
3. Third-line: Oral anticholinergics (glycopyrrolate 1-2 mg once/twice daily or clonidine 0.1 mg twice daily)
4. Fourth-line: Microwave therapy (newer option specifically for axillary hyperhidrosis)
5. Fifth-line: Local procedures (curettage or liposuction)
6. Last resort: Endoscopic thoracic sympathectomy (ETS)

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride
   • For plantar hyperhidrosis, both 12.5% and 30% concentrations are effective and safe 2
2. Second-line: Oral medications
   • Glycopyrrolate (1-2 mg once or twice daily) preferred over clonidine (0.1 mg twice daily) 1, 3
3. Third-line: Iontophoresis
   • 20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance 1
4. Fourth-line: Botulinum toxin injections
   • Effective but painful and requires repeated treatments every 3-9 months 1
5. Fifth-line for palmar only: ETS (not recommended for plantar hyperhidrosis due to anatomic risks) 3

Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1
2. Second-line: Oral medications (glycopyrrolate or clonidine) 3
3. Third-line: Botulinum toxin injections
4. Last resort: ETS for severe cases 3

Application Tips and Considerations

Topical Treatments

• Apply aluminum chloride to completely dry skin at night
• Wash off in the morning
• Common side effect: skin irritation
• Important: Inadequate drying before application reduces effectiveness 1

Iontophoresis

• Low-level electrical current delivered through water
• Highly effective for palmar and plantar hyperhidrosis
• Requires regular maintenance sessions

Botulinum Toxin

• Effective for all focal hyperhidrosis types
• Duration: 3-9 months before repeat treatment needed
• Palmar injections are particularly painful and may require anesthesia

Oral Medications

• Anticholinergics (glycopyrrolate, oxybutynin) can cause significant side effects:
  • Dry mouth, constipation, blurred vision, cognitive effects
  • Contraindicated in glaucoma, myasthenia gravis, and bladder outflow obstruction 1

Surgical Options

• ETS is effective but carries risk of compensatory hyperhidrosis (excessive sweating in untreated areas)
• Should only be considered when other treatments fail

Lifestyle Management

• 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

Treatment Pitfalls to Avoid

• Stopping topical treatments too soon can lead to symptom recurrence
• Inadequate drying before applying aluminum chloride significantly reduces effectiveness
• Underestimating the psychological impact of hyperhidrosis on quality of life
• Jumping to invasive treatments before adequately trialing conservative options

Primary hyperhidrosis is a chronic condition requiring ongoing management, and treatment selection should be guided by the anatomical location of excessive sweating, severity of symptoms, and patient preferences regarding the balance between efficacy, convenience, and side effects.