Treatment of Hyperhidrosis (Excessive Sweating)
For primary hyperhidrosis, start with topical aluminum chloride (10-20%) as first-line therapy for axillary, palmar, and plantar sweating, while topical glycopyrrolate is preferred for craniofacial hyperhidrosis. 1, 2, 3
Initial Evaluation
Before treating, rule out secondary causes by checking:
- Thyroid function tests to exclude hyperthyroidism 1
- Medication review for drugs causing hyperhidrosis 1
- Iron stores, vitamin D, and zinc levels if scalp involvement with scaling 1
Secondary hyperhidrosis requires treating the underlying condition (hyperthyroidism, medications, infections) rather than symptomatic management. 2, 4
Treatment Algorithm by Body Site
Axillary Hyperhidrosis
First-line: Topical aluminum chloride solution (10-20%) applied nightly to dry skin 2, 3, 5. This remains the most cost-effective initial approach despite potential skin irritation. 5
Second-line: OnabotulinumtoxinA (Botox) injections provide 3-9 months of relief and are highly effective 1, 2, 3, 5. This is now considered first- or second-line by some guidelines due to excellent efficacy. 3
Third-line: Oral glycopyrrolate 1-2 mg once or twice daily 1, 2. Monitor for anticholinergic side effects including dry mouth, blurred vision, urinary retention, and constipation. 1, 6
Fourth-line: Local surgical options including curettage, liposuction, or microwave thermolysis 2, 3, 5
Fifth-line: Endoscopic thoracic sympathectomy (ETS) only for severe refractory cases 2, 3
Palmar and Plantar Hyperhidrosis
First-line: Topical aluminum chloride solution 2, 3
Second-line: Oral glycopyrrolate 1-2 mg once or twice daily (preferred over clonidine 0.1 mg twice daily) due to low cost, convenience, and emerging safety data 2. This represents a practical approach before more invasive options.
Third-line: Iontophoresis using tap water with mild electrical current, requiring 3-4 sessions weekly initially, then 1-2 maintenance sessions weekly 6, 2, 5, 4. Adding anticholinergic substances to the water improves rapidity and duration of response. 5
Fourth-line: Botulinum toxin injections, though highly effective, require nerve blocks for pain control in palmar injections and may cause temporary hand muscle weakness 6, 2, 3. Treatment must be repeated every 3-6 months. 2, 4
Fifth-line: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 2, 3
Craniofacial/Scalp Hyperhidrosis
First-line: Oral glycopyrrolate 1-2 mg twice daily or clonidine 0.1 mg twice daily 1, 2. Systemic therapy is preferred over topical for this location due to practical application difficulties.
Second-line: Topical glycopyrrolate for localized areas 3
Alternative: Botulinum toxin injections, though may cause temporary weakness in adjacent facial muscles depending on injection site 1, 2
Severe cases: ETS may be considered 2
Supportive Measures
- Avoid triggers: spicy foods, caffeine, alcohol 1
- Wear moisture-wicking materials and appropriate breathable headwear 1
- Maintain regular scalp hygiene to prevent secondary complications 1
- Monitor for vitamin D deficiency in patients with thick scalp scaling 1
Important Caveats
Compensatory hyperhidrosis is a common and potentially distressing complication of ETS, where patients develop excessive sweating in other body areas (trunk, legs). 4 Patients must be thoroughly counseled about this risk before surgery, as some find it worse than the original condition. 4
Botulinum toxin duration: Effects last 3-9 months, requiring repeated treatments for sustained benefit. 2, 5, 4 Cost and need for repeated procedures must be discussed upfront.
Anticholinergic side effects limit the dose of systemic medications that can be tolerated, potentially preventing adequate sweat control. 2, 4 Regular monitoring every 3-6 months is recommended. 1
Iontophoresis requires commitment: While highly effective and safe long-term, the initial time investment and ongoing maintenance sessions may limit adherence. 2, 5, 4