What are the evaluation and treatment options for hyperhidrosis?

Evaluation and Treatment of Hyperhidrosis

Initial Evaluation

Begin by determining whether the hyperhidrosis is primary (focal, bilateral, symmetric) or secondary (generalized, caused by underlying conditions or medications). 1, 2

Key History Elements

• Location and pattern: Primary hyperhidrosis typically affects axillae, palms, soles, or craniofacial regions bilaterally 3, 4
• Timing: Nocturnal sweating suggests secondary causes requiring evaluation for sleep disorders, cardiovascular disease, endocrine disorders, or neurological conditions 2
• Medication review: Many drugs cause secondary hyperhidrosis 2, 5
• Associated symptoms: Ask about thyroid dysfunction symptoms, sleep disturbances, orthostatic symptoms, and polyuria 2

Physical Examination

• Assess sweating distribution: Focal vs. generalized 4, 5
• Check vital signs: Including orthostatic blood pressure 2
• Examine for thyroid abnormalities and peripheral edema 2
• Inspect scalp for scaling or inflammation if craniofacial involvement 1

Laboratory Testing

For suspected secondary hyperhidrosis, obtain:

• Complete blood count, comprehensive metabolic panel 2
• Thyroid function tests (TSH) 1, 2
• Hemoglobin A1c 2
• Iron studies, vitamin D, zinc levels 1
• Serum calcium if endocrine disorder suspected 2

Additional testing based on clinical suspicion:

• Overnight oximetry or polysomnography for sleep disorders 2
• ECG and BNP for cardiovascular concerns 2
• Morning urine osmolality and PTH for endocrine evaluation 2

Severity Assessment

Use the Hyperhidrosis Disease Severity Scale (HDSS) to guide treatment intensity: 4, 5

• Score 1: Never noticeable, never interferes with activities
• Score 2: Tolerable, sometimes interferes with activities (mild)
• Score 3: Barely tolerable, frequently interferes with activities (moderate)
• Score 4: Intolerable, always interferes with activities (severe)

Treatment Algorithm by Location and Severity

Axillary Hyperhidrosis

First-line (HDSS 2):

• Topical aluminum chloride 10-20% solution applied at bedtime to dry skin 3, 4, 5

First-line (HDSS 3-4):

• Topical aluminum chloride AND/OR botulinum toxin A injections 4, 5
• OnabotulinumtoxinA is FDA-approved for severe axillary hyperhidrosis 1, 5

Second-line:

• Botulinum toxin A injections (50 units per axilla, repeated every 3-6 months) 3, 4

Third-line:

• Oral glycopyrrolate 1-2 mg once or twice daily 1, 3
• Alternative: oral anticholinergics 5, 6

Fourth-line:

• Local surgical excision of sweat glands 3, 4
• Microwave thermolysis device 5, 6

Fifth-line:

• Endoscopic thoracic sympathectomy (ETS) only after all other options fail 3, 4

Palmar and Plantar Hyperhidrosis

First-line (HDSS 2):

• Topical aluminum chloride 10-20% 3, 4

First-line (HDSS 3-4):

• Topical aluminum chloride, botulinum toxin A, AND iontophoresis 4, 5

Second-line:

• Oral glycopyrrolate 1-2 mg once or twice daily (preferred over clonidine 0.1 mg twice daily due to better safety profile) 3

Third-line:

• Tap water iontophoresis (15-20 minute sessions, 3-4 times weekly initially, then maintenance) 3, 4, 5

Fourth-line:

• Botulinum toxin A injections (requires nerve blocks or topical anesthesia due to pain) 3, 4

Fifth-line:

• ETS for palmar hyperhidrosis only (NOT recommended for plantar due to anatomic risks) 3, 4

Craniofacial Hyperhidrosis

First-line:

• Oral glycopyrrolate 1-2 mg once or twice daily OR topical glycopyrrolate 1, 3, 5
• Alternative: clonidine 0.1 mg twice daily 3

Second-line:

• Botulinum toxin A injections (requires careful technique to avoid facial weakness) 1, 3
• Topical aluminum chloride (may cause scalp irritation or scaling) 1, 3

Third-line:

• ETS for severe refractory cases 3

Special Considerations and Pitfalls

Scalp Hyperhidrosis

• Topical aluminum chloride 10-20% may cause irritation or scaling 1
• Check vitamin D levels in patients with thick scaling 1
• Use high-potency topical steroids if inflammation develops 1
• Maintain regular scalp hygiene to prevent secondary complications 1

Nocturnal Hyperhidrosis

• This is almost always secondary hyperhidrosis requiring evaluation for underlying causes 2
• Screen for "SCREeN" conditions: Sleep disorders, Cardiovascular disease, Renal disease, Endocrine disorders, Neurological conditions 2
• Address underlying causes first (CPAP for sleep apnea, optimize heart failure management, treat thyroid dysfunction) 2

Anticholinergic Side Effects

• Common with oral glycopyrrolate: dry mouth, blurred vision, urinary retention, constipation 1, 3
• Monitor elderly patients closely for cognitive effects and fall risk 2
• Follow up every 3-6 months to adjust treatment 1

ETS Complications

• Compensatory hyperhidrosis occurs in up to 80% of patients and may be worse than original symptoms 3, 7
• Gustatory hyperhidrosis, Horner syndrome, and neuralgia are additional risks 7
• Reserve for severe, refractory cases only after exhausting all other options 3, 4

Common Pitfalls to Avoid

• Failing to distinguish primary from secondary hyperhidrosis leads to inappropriate treatment 2, 5
• Overlooking medications as causes of secondary hyperhidrosis 2
• Not using severity scales results in over- or under-treatment 4, 5
• Jumping to ETS without trying conservative measures exposes patients to irreversible complications 3, 4
• Ignoring serious underlying conditions like malignancy in unexplained night sweats 2
• Using nonresorbable packing in patients with hereditary hemorrhagic telangiectasia increases rebleeding risk 8