What should I prescribe for axillary hyperhidrosis?

Treatment Options for Axillary Hyperhidrosis

For axillary hyperhidrosis, first-line treatment should be topical aluminum chloride, followed by botulinum toxin injections if topical treatment fails. 1, 2

First-Line Treatment

• Topical 20% aluminum chloride solution should be applied to completely dry axillae, typically at bedtime when sweating is minimal 1, 2
• The solution should be left on overnight and washed off in the morning 2
• Efficacy varies, with approximately 33% of patients achieving significant improvement 3
• Common side effects include skin irritation and burning sensation 2

Second-Line Treatment

• Botulinum toxin A (onabotulinumtoxinA) injections are recommended when topical aluminum chloride is ineffective or poorly tolerated 1, 2
• Botulinum toxin has superior efficacy compared to aluminum chloride, with 92% of patients achieving significant improvement versus 33% with aluminum chloride 3
• The effect typically lasts 4-6 months, requiring repeat treatments 4
• Intradermal injections of botulinum toxin A are well-tolerated with 98% of patients reporting they would recommend this therapy to others 4

Third-Line Treatment

• Oral anticholinergic medications such as glycopyrrolate (1-2 mg once or twice daily) can be considered when topical treatments and botulinum toxin injections are ineffective 1, 2
• Oral medications have systemic effects and may cause side effects including dry mouth, blurred vision, and urinary retention 1

Fourth-Line Treatment

• Local surgical options including suction-curettage or excision of the axillary sweat glands can be considered for treatment-resistant cases 1, 2
• These procedures are more invasive but may provide long-term relief 1

Fifth-Line Treatment

• Endoscopic thoracic sympathectomy (ETS) should only be considered as a last resort for severe, treatment-resistant axillary hyperhidrosis 1
• This procedure carries risks of compensatory hyperhidrosis in other body regions and should be reserved for the most severe cases 1, 2

Newer Treatment Options

• Microwave thermolysis (miraDry) is a newer non-invasive option for axillary hyperhidrosis that destroys sweat glands using microwave energy 2
• This treatment provides long-lasting results but may require multiple sessions 2

Important Considerations

• The Hyperhidrosis Disease Severity Scale (HDSS) should be used to assess severity and treatment response 2
• Treatment success is typically defined as ≥2-point improvement on the HDSS 3
• Combination therapy may be necessary for severe cases 1
• Patient education about proper application techniques for topical treatments is essential for maximizing efficacy 2