How to manage hyperhidrosis in teenagers?

Management of Hyperhidrosis in Teenagers

Start with topical aluminum chloride solution as first-line treatment for most cases of primary focal hyperhidrosis in teenagers, applying it nightly to affected areas (axillae, palms, or soles). 1

Initial Assessment and Treatment Selection

When evaluating increased sweating in a teenager, first determine whether this is primary (focal, bilateral, symmetric sweating without underlying cause) or secondary hyperhidrosis (caused by medications, hyperthyroidism, or other medical conditions). 1, 2

First-Line Topical Therapy

• Topical aluminum chloride remains the initial treatment of choice for axillary, palmar, and plantar hyperhidrosis due to its effectiveness, safety profile, and ease of application. 3, 1
• Apply at night to dry skin, wash off in the morning; this approach minimizes irritation while maximizing efficacy. 3
• For craniofacial sweating specifically, topical glycopyrrolate is the preferred first-line agent rather than aluminum chloride. 1

Common pitfall: Patients often apply aluminum chloride to wet skin or during the day, which significantly reduces effectiveness and increases irritation risk. 3

Second-Line Options When Topicals Fail

Iontophoresis for Palms and Soles

• Tap water iontophoresis should be considered as second-line treatment for palmoplantar hyperhidrosis. 3, 1, 4
• This method is simple, well-tolerated, and produces no long-term adverse effects in adolescents. 2
• Adding anticholinergic substances to the water produces more rapid therapeutic success with longer-lasting results. 3
• The main limitation is the need for ongoing maintenance treatments to sustain symptom control. 2

Botulinum Toxin Injections

• OnabotulinumtoxinA injection is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis when topical therapy fails. 1
• Efficacy typically lasts 3-9 months for axillary hyperhidrosis, requiring repeat injections for sustained benefit. 3, 2
• This represents an effective and promising alternative, particularly for teenagers who have failed conservative measures. 3

Systemic and Surgical Options for Severe Cases

Oral Anticholinergics

• Systemic anticholinergics are useful adjuncts in severe hyperhidrosis when other treatments fail, but their use is often limited by adverse effects (dry mouth, blurred vision, urinary retention, constipation). 1, 2, 4
• The dose required to control sweating frequently causes significant side effects that limit medication effectiveness. 2

Surgical Interventions

• Reserve surgical options (curettage with scraper, liposuction, or endoscopic thoracic sympathectomy) only after conservative methods have failed. 3, 1
• For axillary hyperhidrosis, curettage and liposuction are reliable and safe treatments. 3
• Local microwave therapy is a newer option specifically for axillary hyperhidrosis. 1

Critical caveat: Endoscopic thoracic sympathectomy, while providing long-term resolution, should only be considered in well-justified cases due to its highly invasive nature and potential complications including compensatory hyperhidrosis (sweating in new areas), gustatory hyperhidrosis, Horner syndrome, and neuralgia—complications that patients may find worse than the original condition. 3, 2

Special Considerations for Adolescents

• Hyperhidrosis typically begins between ages 6-16 years and causes considerable disruption of social life and educational career, leading to severe deterioration in quality of life. 5
• Many treatment modalities lack formal approval for children, making the therapeutic approach more challenging in this age group. 5
• Despite approval limitations, effective therapeutic options exist and should be pursued aggressively given the significant psychosocial impact on teenagers. 5

Treatment Algorithm

Use this stepwise approach:

1. Start: Topical aluminum chloride (or glycopyrrolate for face) applied nightly
2. If inadequate response after 4-6 weeks: Add iontophoresis (for hands/feet) or proceed to botulinum toxin (for axillae/face)
3. If still inadequate: Consider oral anticholinergics as adjunct therapy
4. If refractory to all conservative measures: Evaluate for surgical options (local procedures preferred over sympathectomy)

3, 1, 4