What are the treatment options for hyperhidrosis?

Treatment Options for Hyperhidrosis

The most effective treatment approach for hyperhidrosis follows a stepwise algorithm based on the affected body area, with topical aluminum chloride as first-line therapy for most cases, followed by iontophoresis, oral anticholinergics, botulinum toxin injections, and surgical options for refractory cases. 1, 2

Classification and Evaluation

• Hyperhidrosis is classified as primary (focal, bilateral, symmetric) or secondary (caused by underlying medical conditions or medications) 2
• Evaluation should include checking thyroid function, iron stores, vitamin D, and zinc levels to rule out underlying causes 3
• The Hyperhidrosis Disease Severity Scale can guide treatment decisions based on the impact on quality of life 2

Treatment Algorithm by Anatomical Location

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride (10-20%) 1, 2
2. Second-line: Botulinum toxin injections (onabotulinumtoxinA) 1, 2
3. Third-line: Oral anticholinergics (glycopyrrolate 1-2mg once or twice daily) 1
4. Fourth-line: Local surgical options (curettage, liposuction) 1, 4
5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) 1

Palmar Hyperhidrosis

1. First-line: Topical aluminum chloride (10-20%) 1, 2
2. Second-line: Oral anticholinergics (glycopyrrolate preferred over clonidine) 1
3. Third-line: Iontophoresis (3-4 sessions/week initially, then 1-2 maintenance sessions weekly) 5, 1
4. Fourth-line: Botulinum toxin injections (requires nerve blocks to minimize pain) 5, 1
5. Fifth-line: ETS (for severe cases unresponsive to other treatments) 1, 4

Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride (10-20%) 1, 2
2. Second-line: Oral anticholinergics (glycopyrrolate 1-2mg once or twice daily) 1
3. Third-line: Iontophoresis 1, 2
4. Fourth-line: Botulinum toxin injections 1
5. Note: ETS is not recommended for plantar hyperhidrosis due to anatomic risks 1

Craniofacial Hyperhidrosis

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

Specific Treatment Details

Topical Treatments

• Aluminum chloride (10-20%): Apply to dry skin at night, wash off in morning 2
• Potential side effects: Skin irritation, scaling (particularly on scalp) 3
• For scalp hyperhidrosis: Regular hygiene to prevent secondary complications 3

Iontophoresis

• Mechanism: Mild electrical current passed through water and skin surface 5
• Advantages: Safe, effective, no long-term adverse effects 6
• Disadvantages: Requires maintenance treatments, initial cost and inconvenience 1

Oral Medications

• Glycopyrrolate (1-2mg once or twice daily): Most preferred anticholinergic 1
• Side effects: Dry mouth, blurred vision, urinary retention, constipation 3, 5
• Clonidine (0.1mg twice daily): Alternative option 1

Botulinum Toxin Injections

• Efficacy: High, with effects lasting 3-9 months 1, 4
• Limitations: Expensive, requires repeat treatments, pain during administration 1
• For palmar injections: Nerve blocks recommended to minimize pain 5
• Side effects: Temporary muscle weakness, especially in hand muscles for palmar treatment 5

Surgical Options

• Local procedures for axillary hyperhidrosis: Curettage with a scraper, liposuction 4
• ETS: Effective but invasive with risk of compensatory hyperhidrosis, Horner syndrome, and neuralgia 6, 4
• Should only be considered when all other treatments have failed 4

Lifestyle Modifications

• Avoid known triggers: Spicy foods, caffeine, alcohol 3
• Wear moisture-wicking materials and appropriate headwear 3, 5
• Regular monitoring for side effects of medications, particularly anticholinergics 3
• Follow-up every 3-6 months to adjust treatment as needed 3

Treatment Considerations for Special Populations

• For thick scaling conditions affecting the scalp: Check vitamin D levels and consider topical high-potency steroids for inflammation 3
• For medication-induced hyperhidrosis: Address the underlying cause by adjusting medication when possible 5