What are the causes and treatment options for palmar hyperhidrosis?

Causes and Treatment of Palmar Hyperhidrosis

Palmar hyperhidrosis is primarily treated with topical aluminum chloride as first-line therapy, followed by iontophoresis, oral anticholinergics, botulinum toxin injections, and surgical options for severe cases that don't respond to other treatments. 1

Causes of Palmar Hyperhidrosis

• Primary hyperhidrosis: Bilaterally symmetric, focal excessive sweating of the palms not caused by underlying conditions, typically beginning in childhood or adolescence 1, 2

• Secondary hyperhidrosis: May be caused by underlying medical conditions or medications 1

• Hypohidrosis in certain skin conditions: In some dermatological conditions like congenital ichthyoses, hypohidrosis can occur due to plugging of sweat ducts by hyperkeratosis 3

• Medication-induced hyperhidrosis: Can occur as a side effect of certain anticancer agents, presenting as palmar-plantar erythrodysesthesia syndrome (PPES) 3

Treatment Algorithm for Palmar Hyperhidrosis

First-Line Treatment:

• Topical aluminum chloride solution: Apply to dry palms, preferably at night and wash off in the morning 1, 4
  • Most effective when applied to completely dry skin
  • Can be used under occlusion for enhanced effect

Second-Line Treatment:

• Oral anticholinergic medications: 4
  • Glycopyrrolate 1-2 mg once or twice daily (preferred)
  • Clonidine 0.1 mg twice daily as an alternative
  • Monitor for side effects including dry mouth, blurred vision, urinary retention

Third-Line Treatment:

• Iontophoresis: Safe, effective treatment specifically for palmar hyperhidrosis 5, 6
  • Involves passing a mild electrical current through water and the skin surface
  • Typically requires 3-4 sessions per week initially, then 1-2 maintenance sessions weekly
  • Can be combined with anticholinergics for enhanced effect

Fourth-Line Treatment:

• Botulinum toxin injections (onabotulinumtoxinA): 1, 4
  • Highly effective but temporary (lasts 3-6 months)
  • Requires painful injections that may need anesthesia
  • Expensive and must be repeated regularly
  • May cause temporary weakness in hand muscles

Fifth-Line Treatment:

• Endoscopic thoracic sympathectomy (ETS): Surgical option for severe, treatment-resistant cases 4, 6
  • Permanent but carries risk of compensatory hyperhidrosis (excessive sweating in other body areas)
  • Should only be considered after failure of all other treatment options
  • Requires thorough discussion of potential complications with patients

Special Considerations

• Assessment: Use the Hyperhidrosis Disease Severity Scale to grade severity and impact on quality of life to guide treatment decisions 1

• Combination therapy: For severe cases, combining treatments may be more effective than monotherapy 5

• Behavioral modifications: 1

  • Avoid triggers (spicy foods, caffeine, alcohol)
  • Wear moisture-wicking materials
  • Use absorbent materials when needed

• Treatment of secondary causes: If hyperhidrosis is secondary to another condition, treating the underlying cause is essential 1, 2

• Hypohidrosis management: In cases where hypohidrosis is the issue (as in some skin conditions), regular topical skincare and avoiding extreme temperatures are recommended 3

• Caution with anticancer treatments: In patients receiving chemotherapy who develop palmar-plantar reactions, specific protocols including topical steroids and dose adjustments may be needed 3