What medications are used to treat palmar and plantar hyperhidrosis?

Medications for Palmar and Plantar Hyperhidrosis

Topical aluminum chloride is the first-line treatment for palmar and plantar hyperhidrosis, with oral anticholinergics like glycopyrrolate recommended as second-line therapy when topical treatments fail. 1

First-Line Treatment Options

Topical Treatments

• Aluminum chloride (10-20%) applied to dry skin at night and washed off in the morning
  • Apply to completely dry skin to maximize effectiveness
  • Cover with plastic wrap or wear cotton gloves/socks overnight to enhance penetration
  • Most effective when skin is completely dry before application 1
  • May cause skin irritation in some patients

Second-Line Treatment Options

Oral Medications

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

  • Works by blocking acetylcholine receptors to reduce sweat production
  • Preferred over clonidine due to better safety profile 1
  • Side effects include dry mouth, blurred vision, urinary retention, and constipation
  • Contraindicated in patients with glaucoma, myasthenia gravis, and certain GI conditions 2

• Oxybutynin

  • Antimuscarinic agent that inhibits acetylcholine action on smooth muscle
  • Relaxes smooth muscle and decreases glandular secretions
  • Side effects similar to glycopyrrolate 2

Third-Line Treatment Options

Iontophoresis

• Delivers mild electrical current through water to temporarily block sweat glands
• Highly effective for palmoplantar hyperhidrosis with minimal side effects 3
• Treatment protocol:
  • Initial phase: 20-30 minute sessions, 3-4 times per week for 3-4 weeks
  • Maintenance: 1-2 sessions weekly or as needed
• Can be enhanced with aluminum chloride (1%) solution instead of tap water 4
• Side effects include mild discomfort, erythema, and vesiculation

Fourth-Line Treatment Options

Botulinum Toxin Injections

• Highly effective for palmoplantar hyperhidrosis 5
• Effects last 6-9 months on average
• Limitations:
  • Expensive treatment that must be repeated every 3-6 months
  • Painful procedure often requiring nerve blocks or anesthesia
  • May cause temporary weakness in hand muscles when used for palmar hyperhidrosis 6

Fifth-Line Treatment Option

Surgical Intervention

• Endoscopic Thoracic Sympathectomy (ETS)
  • Reserved for severe, treatment-resistant palmar hyperhidrosis
  • Not recommended for plantar hyperhidrosis due to anatomical risks 1
  • Potential complications include compensatory hyperhidrosis in other body areas

Special Considerations

• Treatment algorithm should progress stepwise from least to most invasive options
• Combination therapy may be more effective than monotherapy in severe cases
• Quality of life impact should guide treatment aggressiveness, as palmoplantar hyperhidrosis can significantly impair daily functioning
• Compensatory hyperhidrosis is a risk with more invasive treatments, particularly ETS

Monitoring and Follow-up

• Assess treatment efficacy using the Hyperhidrosis Disease Severity Scale 6
• Adjust treatment based on response and side effects
• Consider combination therapy for inadequate response to single-agent treatment

For optimal outcomes, treatment should begin with topical aluminum chloride and progress through the treatment algorithm only when response is inadequate, balancing efficacy against side effects and invasiveness.