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

Treatment Options for Hyperhidrosis in Children

The management of hyperhidrosis in children should follow a stepwise approach, starting with topical aluminum chloride as first-line treatment for most cases of primary focal hyperhidrosis, followed by iontophoresis for palmar and plantar hyperhidrosis, and botulinum toxin injections for persistent cases. 1

Understanding Pediatric Hyperhidrosis

Hyperhidrosis in children typically begins between 6 and 16 years of age 2 and can significantly impact quality of life, social interactions, and educational performance. The condition is characterized by excessive sweating beyond what is physiologically necessary for thermoregulation and can be:

• Primary hyperhidrosis: Localized, idiopathic, and typically affecting axillae, palms, soles, or face
• Secondary hyperhidrosis: Caused by underlying medical conditions or medications

First-Line Treatments

Topical Treatments

• Aluminum chloride solution: First-line treatment for most cases of primary focal hyperhidrosis 1

  • Apply to affected areas at night when sweat glands are less active
  • Wash off in the morning
  • Start with lower concentrations for children to minimize irritation

• Topical glycopyrrolate: First-line treatment specifically for craniofacial sweating 1

Environmental and Lifestyle Modifications

• Proper hydration: Ensure adequate hydration before, during, and after activities 3
• Appropriate clothing: Recommend loose-fitting, light-colored, moisture-wicking clothing 3
• Environmental control: Avoid hot environments when possible to prevent excessive sweating 3

Second-Line Treatments

Iontophoresis

• Should be considered for treating hyperhidrosis of the palms and soles 1
• Involves passing a mild electrical current through water to temporarily block sweat glands
• Generally safe for children but may require supervision
• Treatment sessions typically last 20-30 minutes and are repeated several times per week initially

Botulinum Toxin Injections (OnabotulinumtoxinA)

• Considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis 1
• May require pain management strategies when used in children
• Effects typically last 4-6 months, requiring repeat treatments

Third-Line Treatments

Oral Anticholinergics

• Useful adjuncts in severe cases when other treatments fail 1
• Examples include glycopyrrolate and oxybutynin
• Caution: Side effects may include dry mouth, blurred vision, urinary retention, and constipation
• Dosing should be carefully adjusted for pediatric patients

Advanced Options for Severe Cases

• Microwave therapy: Newer treatment option for axillary hyperhidrosis in older children/adolescents 1
• Surgical interventions: Consider only in severe cases unresponsive to other therapies 1
  • Local surgery for axillary hyperhidrosis
  • Endoscopic thoracic sympathectomy as a last resort

Treatment Algorithm

1. Initial assessment:

   • Determine if hyperhidrosis is primary or secondary
   • Assess severity using Hyperhidrosis Disease Severity Scale
   • Identify affected body areas

2. Start with least invasive options:

   • Topical aluminum chloride for most locations
   • Topical glycopyrrolate for facial hyperhidrosis
   • Environmental and clothing modifications

3. If inadequate response after 2-4 weeks:

   • For palmar/plantar: Add iontophoresis
   • For axillary/facial: Consider botulinum toxin injections

4. For persistent severe cases:

   • Add oral anticholinergics
   • Consider referral for specialized treatments (microwave therapy, surgical options)

Important Considerations for Pediatric Patients

• Treatment must account for the psychological impact of hyperhidrosis on children's development and social interactions
• Lower doses of medications are typically required compared to adults
• Long-term safety profiles should be carefully considered
• Involve parents/caregivers in treatment decisions and management

Pitfalls to Avoid

• Undertreatment: Hyperhidrosis remains widely underdiagnosed and undertreated in pediatric patients 4
• Overtreatment: Avoid jumping to invasive procedures before trying conservative approaches
• Ignoring psychological impact: Address the emotional distress and social impairment associated with the condition
• Missing secondary causes: Always rule out underlying medical conditions before diagnosing primary hyperhidrosis

Early detection and appropriate management of hyperhidrosis can significantly improve a child's quality of life and prevent long-term psychological consequences.