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

Treatment Options for Hyperhidrosis (Excessive Sweating)

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

Classification and Assessment

Hyperhidrosis can be categorized into two main types:

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

The Hyperhidrosis Disease Severity Scale (HDSS) is recommended to assess treatment effectiveness, with treatment considered successful when the HDSS score is reduced to less than 2 1.

Treatment Algorithm Based on Affected Area

1. Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride (15% solution) 1
2. Second-line: Botulinum toxin A injections (200 U) - reduces sweat production from 192 mg/min to 24 mg/min after two weeks, with effects lasting 3-9 months 2
3. Third-line: Microwave therapy (newer option specifically for axillary hyperhidrosis) 1
4. Last resort: Local procedures such as curettage or liposuction 1

2. Palmar and Plantar Hyperhidrosis

1. First-line: Iontophoresis (20-30 minute sessions, 3-4 times weekly initially, then 1-2 times weekly for maintenance) 1
2. Second-line: Botulinum toxin injections (can be painful but effective) 1
3. Last resort: Endoscopic thoracic sympathectomy (ETS) for severe, treatment-resistant cases 1

3. Craniofacial Hyperhidrosis

1. First-line: Topical glycopyrrolate 1, 3
2. Second-line: Botulinum toxin injections 3

Systemic Treatments for Widespread or Severe Hyperhidrosis

When topical or local treatments fail, systemic medications may be considered:

• Glycopyrrolate: 1-2 mg once or twice daily 1
• Oxybutynin: Starting at 0.02 mg/kg three times daily, gradually increasing to approximately 0.1 mg/kg three times daily (not exceeding 3 mg three times daily) 4
• Clonidine: 0.1 mg twice daily 1

Important Cautions and Considerations

• Heat-related concerns: Anticholinergic medications can reduce sweating and increase risk of heat prostration. Patients should avoid exposure to hot or very warm environmental temperatures 4
• Side effects of anticholinergics: Include dry mouth, constipation, blurred vision, and cognitive effects. Contraindicated in patients with glaucoma, myasthenia gravis, and significant bladder obstruction 1
• Timing of medication: Glycopyrrolate should be administered at least one hour before or two hours after meals, as high-fat food reduces its bioavailability 4
• Monitoring: For constipation, particularly within 4-5 days of initial dosing or after a dose increase 4

Secondary Hyperhidrosis

Always investigate for underlying causes, particularly for new-onset hyperhidrosis in adulthood:

• Thyroid function tests to rule out hyperthyroidism 1
• Evaluate for diabetic autonomic neuropathy, especially if hyperhidrosis affects face and upper body while lower extremities have anhidrosis 1
• Consider medication side effects as potential causes 1

Lifestyle Modifications

• Wear moisture-wicking clothing 1
• Avoid extreme temperatures and outdoor activities during hot periods 1
• Use cooling devices in hot environments 1
• Apply cold water or packs regularly to help cool the skin 1

By following this treatment algorithm based on the affected area and severity of hyperhidrosis, most patients can achieve significant improvement in their symptoms and quality of life.