What are the treatment options for hyperhidrosis?

Treatment for Hyperhidrosis

For primary hyperhidrosis, start with topical aluminum chloride (10-20%) as first-line therapy for axillary, palmar, and plantar sweating, while oral glycopyrrolate (1-2 mg once or twice daily) is preferred for craniofacial hyperhidrosis. 1, 2, 3

Initial Assessment

Before initiating treatment, evaluate for secondary causes by checking:

• Thyroid function tests 1
• Iron stores 1
• Vitamin D levels 1
• Zinc levels 1
• Medication review for drug-induced sweating 1

Treatment Algorithm by Anatomic Site

Axillary Hyperhidrosis

First-line: Topical aluminum chloride solution (10-20%) applied to dry skin at bedtime 1, 2, 3, 4

Second-line: OnabotulinumtoxinA (Botox) injections, which provide 3-9 months of relief 1, 2, 3, 4

• Potential side effects include temporary weakness in adjacent muscles depending on injection site 1

Third-line: Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily preferred) 2, 3

• Side effects include dry mouth, blurred vision, urinary retention, and constipation 1

Fourth-line: Local surgical options including microwave therapy, curettage, or liposuction 2, 3, 4

Fifth-line: Endoscopic thoracic sympathectomy (ETS) for severe refractory cases 2, 3, 5

Palmar and Plantar Hyperhidrosis

First-line: Topical aluminum chloride solution (10-20%) 2, 3, 4

Second-line: Oral glycopyrrolate (1-2 mg once or twice daily) or clonidine (0.1 mg twice daily) 2

• This recommendation prioritizes cost-effectiveness and convenience over other options 2

Third-line: Tap water iontophoresis 2, 3, 4, 5

• High efficacy but requires ongoing maintenance treatments 4, 5
• Adding anticholinergic substances to water produces more rapid and longer-lasting results 4

Fourth-line: OnabotulinumtoxinA injections 2, 3, 5

• Requires repeat treatments every 3-6 months 2, 5
• Associated with pain and potential anesthesia-related complications 2

Fifth-line: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 2, 5

Craniofacial Hyperhidrosis

First-line: Oral glycopyrrolate (1-2 mg twice daily) or clonidine (0.1 mg twice daily) 1, 2

Second-line: Topical glycopyrrolate 3

Alternative: OnabotulinumtoxinA injections for localized areas 1, 2

Last resort: ETS for severe refractory cases 2

Adjunctive Measures

Lifestyle Modifications

• Avoid triggers including spicy foods, caffeine, and alcohol 1
• Wear moisture-wicking materials and appropriate headwear 1
• Avoid extreme temperatures and outdoor activities during hottest periods 6
• Use cooling devices (air conditioning, fans), cold water sprays, or cold packs 6

Scalp-Specific Considerations

• Maintain regular scalp hygiene to prevent secondary complications 1
• Topical aluminum chloride may cause irritation or scaling of the scalp 1
• Check vitamin D levels if thick scaling develops 1
• Use topical high-potency steroids if inflammation develops 1

Important Caveats

Surgical considerations: ETS can cause compensatory hyperhidrosis, gustatory hyperhidrosis, Horner syndrome, and neuralgia—complications that patients may find worse than the original condition 5. Reserve surgery only after conservative treatments have failed 4, 5.

Botulinum toxin limitations: While highly effective, this treatment requires repeat injections every 3-9 months, is expensive, and involves procedural discomfort 2, 4, 5.

Anticholinergic side effects: Systemic anticholinergics are often limited by their adverse effect profile, particularly dry mouth, blurred vision, urinary retention, and constipation 1, 5. Monitor patients regularly for these side effects 1.

Monitoring

• Follow-up every 3-6 months to adjust treatment as needed 1
• Monitor for medication side effects, particularly with anticholinergics 1
• Assess treatment efficacy using the Hyperhidrosis Disease Severity Scale 3