What are the treatment options for hyperhidrosis (excessive perspiration) of the palms and soles?

Treatment of Excessive Perspiration of Palms and Soles (Hyperhidrosis)

For palmar and plantar hyperhidrosis, begin with topical aluminum chloride 20% solution applied nightly as first-line therapy, then escalate to iontophoresis or oral glycopyrrolate (1-2 mg once or twice daily) as second-line treatment, reserving botulinum toxin injections for refractory cases. 1, 2, 3

First-Line Treatment: Topical Aluminum Chloride

• Apply 20% aluminum chloride hexahydrate in anhydrous ethyl alcohol to affected palms and soles at bedtime, covering with plastic wrap or occlusion if tolerated 3, 4, 5
• This remains the most cost-effective initial approach with proven efficacy for mild to moderate hyperhidrosis (HDSS score of 2) 2, 6, 5
• Patients typically see definite reduction in sweating within weeks of consistent nightly application 4

Common pitfall to avoid: Many patients discontinue aluminum chloride prematurely due to skin irritation. Instruct patients to apply only to completely dry skin and consider alternating nights if irritation develops.

Second-Line Treatment Options

Iontophoresis (Preferred for Palms and Soles)

• Tap water iontophoresis is the method of choice for palmoplantar hyperhidrosis when topical aluminum chloride fails 1, 6, 5
• Requires 3-4 treatment sessions per week initially (20-30 minutes per session), then 1-2 maintenance sessions weekly 1
• This therapy passes a mild electrical current through water and the skin surface, with high efficacy despite initial time commitment 1, 2
• Adding anticholinergic substances to the water produces more rapid and longer-lasting therapeutic success 6

Oral Anticholinergic Medications

• Glycopyrrolate 1-2 mg once or twice daily is preferred over clonidine 0.1 mg twice daily due to emerging literature supporting excellent safety and reasonable efficacy 1, 2
• This option offers low cost and convenience compared to iontophoresis 2
• Monitor for anticholinergic side effects: dry mouth, blurred vision, urinary retention, and constipation 1
• Consider this as second-line therapy alongside iontophoresis, particularly for patients who cannot commit to the time requirements of iontophoresis 2

Third-Line Treatment: Botulinum Toxin Injections

• OnabotulinumtoxinA injections are highly effective but reserved for refractory cases due to cost, need for repeated treatments every 3-6 months, and procedural pain 1, 2, 3
• Use nerve blocks before injection to minimize pain during administration, particularly for palmar injections 1
• May cause temporary weakness in hand muscles, which is a significant consideration for patients requiring fine motor skills 1
• Despite these limitations, botulinum toxin is considered first- or second-line by some guidelines for severe cases (HDSS score 3-4) 3, 5

Fourth-Line Treatment: Surgical Options

• Endoscopic thoracic sympathectomy (ETS) should only be considered after failure of all conservative treatments for severe palmar hyperhidrosis 2, 3, 5
• ETS is not recommended for plantar hyperhidrosis due to anatomic risks and lack of accessible sympathetic pathways 2
• This invasive procedure carries risk of compensatory hyperhidrosis (sweating in other body areas), which can be more bothersome than the original condition 2, 6

Treatment Algorithm Based on Severity

For Mild Hyperhidrosis (HDSS Score 2):

1. Topical aluminum chloride 20% nightly 5
2. If failure: Add iontophoresis OR oral glycopyrrolate 2, 5
3. If failure: Botulinum toxin injections 5

For Severe Hyperhidrosis (HDSS Score 3-4):

1. Both topical aluminum chloride AND iontophoresis as first-line therapy 5
2. Consider oral glycopyrrolate 1-2 mg once or twice daily as adjunct 2
3. If failure: Botulinum toxin injections 5
4. If failure: Consider ETS (palms only) 2, 5

Behavioral Modifications as Adjunct

• Avoid known triggers that worsen sweating 1
• Wear moisture-wicking materials and breathable footwear 1
• These modifications alone are insufficient but enhance efficacy of medical treatments 1

Critical Distinction: This is NOT Palmoplantar Psoriasis

The evidence provided includes extensive discussion of palmoplantar psoriasis treatment (acitretin, PUVA, biologics), which presents with erythematous scaly and fissured hyperkeratotic plaques—this is a completely different condition from hyperhidrosis 7. If your patient has scaly, hyperkeratotic lesions rather than pure excessive sweating, refer to dermatology for evaluation of psoriasis or other dermatologic conditions.