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 Diagnosis

Hyperhidrosis is characterized by excessive sweating beyond what is needed for thermoregulation and can be classified into two main categories:

• Primary (focal) hyperhidrosis: Bilaterally symmetric, affecting specific areas such as axillae, palms, soles, and craniofacial region
• Secondary hyperhidrosis: May be focal or generalized, caused by underlying medical conditions or medications

Diagnosis should include assessment with the Hyperhidrosis Disease Severity Scale (HDSS), with treatment considered successful when the HDSS score is reduced to <2 1.

Treatment Algorithm by Anatomical Site

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride (15% solution) 1
2. Second-line: Botulinum toxin injections 1, 2
3. Third-line: Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily) 2
4. Fourth-line: Microwave therapy or local surgery 1, 2
5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) 2

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 2, 3
2. Second-line: Oral medications (glycopyrrolate 1-2 mg once or twice daily preferred over clonidine 0.1 mg twice daily) 2
3. Third-line: Iontophoresis (20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance) 1, 2
4. Fourth-line: Botulinum toxin injections 2
5. Fifth-line: ETS (for palmar only, not recommended for plantar due to anatomic risks) 2

Craniofacial Hyperhidrosis

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

Medication Details

Topical Treatments

• Aluminum chloride (15% solution): Apply to dry skin at bedtime, wash off in morning 1
• Topical glycopyrrolate: Preferred for craniofacial hyperhidrosis 1

Systemic Medications

• Glycopyrrolate (oral):

  • Dosage: 1-2 mg once or twice daily 2
  • Side effects: Dry mouth, constipation, blurred vision, cognitive effects 1
  • Contraindications: Glaucoma, myasthenia gravis, significant bladder outflow obstruction 1, 4

• Oxybutynin (anticholinergic):

  • Side effects: Dry mouth, constipation, blurred vision, cognitive effects 5
  • Cautions: Use with caution in patients with glaucoma, myasthenia gravis, GI disorders, and elderly patients 5

Procedural Treatments

• 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
  • Best for: Palmar and plantar hyperhidrosis 1

• Botulinum toxin injections:

  • Efficacy: High, but requires repeated treatments every 3-9 months
  • Limitations: Can be painful, especially for palmar/plantar areas 1, 2

• Microwave therapy:

  • Newer option specifically for axillary hyperhidrosis 1

• Surgical options:

  • Local procedures (curettage or liposuction) for axillary hyperhidrosis 1
  • Endoscopic thoracic sympathectomy (ETS) as last resort for severe, treatment-resistant cases 1
  • Caution: ETS can result in compensatory hyperhidrosis 1

Important Considerations and Pitfalls

• Heat sensitivity: Patients using anticholinergics should avoid extreme temperatures and outdoor activities during hot periods due to risk of heat prostration (fever and heat stroke due to decreased sweating) 1, 4, 5

• Medication interactions: Anticholinergics may interact with other medications that produce dry mouth, constipation, or somnolence, increasing the frequency/severity of these effects 5

• Secondary causes: Always rule out underlying medical conditions (hyperthyroidism, hyperpituitarism, autonomic dysreflexia) before treating primary hyperhidrosis 1

• Clothing recommendations: Patients should wear appropriate moisture-wicking clothing to help manage symptoms 1

• Timing of medication: Glycopyrrolate oral solution should be dosed at least one hour before or two hours after meals, as high-fat food reduces oral bioavailability 4

By following this algorithmic approach and considering the specific anatomical location of hyperhidrosis, most patients can achieve significant improvement in their symptoms and quality of life.