What are the treatment options for hyperhidrosis (excessive sweating)?

Hyperhidrosis Management

For primary focal hyperhidrosis, start with topical aluminum chloride 10-20% as first-line therapy for axillary, palmar, and plantar sweating, while topical or oral glycopyrrolate 1-2 mg once or twice daily should be used first-line for craniofacial hyperhidrosis. 1, 2

Initial Assessment

Distinguish Primary from Secondary Hyperhidrosis

• Primary hyperhidrosis presents bilaterally and symmetrically in axillae, palms, soles, or craniofacial regions 1, 2
• Nocturnal sweating strongly suggests secondary causes requiring evaluation for sleep disorders, cardiovascular disease, endocrine disorders, or neurological conditions 1
• Review all medications as many drugs cause secondary hyperhidrosis 1

Key Clinical Features to Assess

• Assess for thyroid dysfunction symptoms, sleep disturbances, orthostatic symptoms, and polyuria 1
• Check vital signs including orthostatic blood pressure 1
• Examine sweating distribution, thyroid abnormalities, peripheral edema, and scalp for scaling or inflammation if craniofacial involvement present 1

Laboratory Evaluation for Secondary Hyperhidrosis

• Obtain complete blood count, comprehensive metabolic panel, thyroid function tests, hemoglobin A1c, iron studies, vitamin D, zinc levels, and serum calcium 1
• Consider overnight oximetry or polysomnography for sleep disorders, ECG and BNP for cardiovascular concerns, and morning urine osmolality and PTH for endocrine evaluation based on clinical suspicion 1

Treatment Algorithm by Location

Axillary Hyperhidrosis

First-line:

• Topical aluminum chloride 10-20% solution applied to dry skin at bedtime 3, 2, 4
• This remains the method of choice despite newer alternatives 3

Second-line:

• OnabotulinumtoxinA injections (FDA-approved for severe axillary hyperhidrosis) administered at the dermal-subcutaneous junction, providing efficacy for 3-9 months 1, 5, 3
• Iontophoresis can be considered 2

Third-line:

• Oral glycopyrrolate 1-2 mg once or twice daily 1
• Microwave thermolysis for refractory cases 5, 2

Surgical options (last resort):

• Axillary curettage with liposuction for treatment failures 3, 4
• Endoscopic thoracic sympathectomy only after conservative treatments fail, with informed consent regarding compensatory hyperhidrosis risk 5, 2

Palmar and Plantar Hyperhidrosis

First-line:

• Tap water iontophoresis is the primary remedy for palmar and plantar hyperhidrosis 5, 3, 2, 4
• Adding anticholinergic substances to the water produces more rapid and longer-lasting therapeutic success 3

Second-line:

• Botulinum toxin A injections (effective but require repeat treatments every 6-8 months) 5, 3, 6
• Topical aluminum chloride 2

Third-line:

• Oral anticholinergics for severe cases 2

Last resort:

• Sympathectomy only in well-justified cases due to highly invasive nature and risk of compensatory hyperhidrosis 3, 6

Craniofacial Hyperhidrosis

First-line:

• Topical glycopyrrolate or oral glycopyrrolate 1-2 mg once or twice daily 1, 2

Second-line:

• Botulinum toxin A injections using careful technique to avoid facial weakness 1, 2

Important considerations:

• Topical aluminum chloride 10-20% may cause irritation or scaling on the scalp 1
• Check vitamin D levels in patients with thick scalp scaling 1
• Use high-potency topical steroids if inflammation develops 1

Systemic Therapy Considerations

Oral Anticholinergics

• Reserved for treatment-resistant cases or generalized hyperhidrosis 5, 2
• Glycopyrrolate 1-2 mg once or twice daily is the preferred agent 1
• Monitor elderly patients closely for cognitive effects and fall risk 1
• Common anticholinergic side effects include dry mouth, blurred vision, urinary retention, and constipation 1
• Dose required to control sweating often causes significant adverse effects, limiting effectiveness 6

Critical Pitfalls to Avoid

• Failing to distinguish primary from secondary hyperhidrosis leads to inappropriate treatment 1
• Overlooking medications as causes of secondary hyperhidrosis 1
• Ignoring serious underlying conditions like malignancy in unexplained night sweats 1
• Nocturnal hyperhidrosis is almost always secondary and requires evaluation for underlying causes 1
• Proceeding to sympathectomy without exhausting conservative options and without discussing compensatory hyperhidrosis risk 5, 3

Treatment Sequencing Approach

Step 1: Topical therapy (aluminum chloride for axillary/palmar/plantar; glycopyrrolate for craniofacial) 1, 3, 2

Step 2: Iontophoresis for palmar/plantar; botulinum toxin for axillary/craniofacial 1, 5, 2

Step 3: Oral anticholinergics as adjunct therapy 1, 2

Step 4: Energy-based devices (microwave thermolysis, lasers) for axillary hyperhidrosis 5, 2

Step 5: Local surgical excision/curettage for axillary; sympathectomy as absolute last resort 5, 3, 2