What medication treatment is used for hyperhidrosis (excessive sweating)?

Medication Treatment for Excessive Sweating (Hyperhidrosis)

For primary focal hyperhidrosis, topical aluminum chloride is the first-line medication treatment, followed by topical glycopyrronium for axillary hyperhidrosis or topical glycopyrrolate for craniofacial sweating, with botulinum toxin injections and oral anticholinergics (glycopyrrolate or clonidine) as subsequent options depending on the anatomic site affected. 1, 2, 3

First-Line Topical Medications

Aluminum Chloride

• Topical aluminum chloride solution is the initial treatment for most cases of primary focal hyperhidrosis affecting the axillae, palms, and soles 2
• Quick and easy to apply, though it can cause skin irritation and has a short half-life 4
• Remains the tried-and-true procedure with a firm place in hyperhidrosis treatment 5

Topical Anticholinergics

• Topical glycopyrronium is the first-line pharmacological treatment for axillary hyperhidrosis in patients with moderate to severe disease poorly controlled with topical antiperspirants 3
• Supported by at least 8 clinical trials enrolling more than 2000 patients 3
• Topical glycopyrrolate is first-line treatment specifically for craniofacial sweating 2

Second-Line Treatments

Botulinum Toxin Injections

• Botulinum toxin (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis 2
• For axillary hyperhidrosis specifically, botulinum toxin injections are recommended as second-line treatment after topical therapy 1
• Efficacy lasts 3-9 months for axillary hyperhidrosis 5
• Requires repeat injections every 3-6 months to maintain benefits 4
• For palmoplantar hyperhidrosis, considered fourth-line treatment due to high cost, need for repeated treatments, and pain/anesthesia-related complications 1

Oral Anticholinergics

• For palmar and plantar hyperhidrosis, oral medications (glycopyrrolate 1-2 mg once or twice daily preferred over clonidine 0.1 mg twice daily) are recommended as second-line therapy due to low cost, convenience, and emerging literature supporting excellent safety and reasonable efficacy 1
• For craniofacial hyperhidrosis, oral medications (either glycopyrrolate or clonidine) are considered first-line therapy 1
• For axillary hyperhidrosis, oral medications are third-line treatment 1
• Anticholinergics reduce sweating but the dose required to control sweating can cause significant adverse effects (dry mouth, blurred vision, urinary retention), limiting effectiveness 4
• Useful adjuncts in severe cases when other treatments fail 2

Site-Specific Treatment Algorithms

Axillary Hyperhidrosis

1. First-line: Topical aluminum chloride or topical glycopyrronium 2, 3
2. Second-line: Botulinum toxin injections 1
3. Third-line: Oral anticholinergics (glycopyrrolate or clonidine) 1
4. Fourth-line: Local surgery 1
5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) 1

Palmar and Plantar Hyperhidrosis

1. First-line: Topical aluminum chloride 2
2. Second-line: Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily preferred) 1
3. Third-line: Iontophoresis (tap water iontophoresis is the method of choice, with high efficacy though initial cost and inconvenience are considerations) 1, 5
4. Fourth-line: Botulinum toxin injections 1
5. Fifth-line: ETS for palmar only (not recommended for plantar due to anatomic risks) 1

Craniofacial Hyperhidrosis

1. First-line: Oral anticholinergics (glycopyrrolate or clonidine) 1
2. Alternative options: Topical glycopyrrolate or botulinum toxin injections may be useful in some cases 1, 2
3. Severe cases: ETS is an option 1

Important Caveats

• Distinguish primary from secondary hyperhidrosis: If hyperhidrosis is caused by an underlying condition (hyperthyroidism, pheochromocytoma, medications), treat the primary cause rather than using symptomatic treatments 4, 5
• Iontophoresis considerations: Adding anticholinergic substances to the water produces more rapid therapeutic success that lasts longer 5
• Surgical options: Should not be considered until conservative methods have failed 5
• ETS complications: Can cause compensatory and gustatory hyperhidrosis, Horner syndrome, and neuralgia, which patients may find worse than the original condition 4