What are the treatment options for hyperhidrosis?

Treatment of Hyperhidrosis

For primary hyperhidrosis, treatment should be selected based on anatomic location, with topical aluminum chloride 10-20% as first-line therapy for axillary and palmoplantar disease, while oral glycopyrrolate 1-2 mg once or twice daily is first-line for craniofacial hyperhidrosis. 1, 2

Initial Evaluation to Distinguish Primary from Secondary Hyperhidrosis

Before initiating treatment, determine whether hyperhidrosis is primary or secondary:

• Primary hyperhidrosis affects axillae, palms, soles, or craniofacial regions bilaterally and symmetrically 1, 3
• 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
• Check for associated symptoms: thyroid dysfunction, sleep disturbances, orthostatic symptoms, polyuria 1
• Measure orthostatic blood pressure 1
• Examine sweating distribution, thyroid abnormalities, peripheral edema, and scalp for scaling/inflammation if craniofacial involvement present 1, 2

Laboratory Testing for Suspected Secondary Hyperhidrosis

Order: complete blood count, comprehensive metabolic panel, thyroid function tests, hemoglobin A1c, iron studies, vitamin D, zinc levels, and serum calcium 1, 2. Additional testing based on clinical suspicion may include overnight oximetry or polysomnography for sleep disorders, ECG and BNP for cardiovascular concerns, and morning urine osmolality and PTH for endocrine evaluation 1.

Treatment Algorithm by Anatomic Location

Axillary Hyperhidrosis

First-line: Topical aluminum chloride 10-20% solution applied to dry skin at bedtime 1, 3, 4, 5

Second-line: OnabotulinumtoxinA (Botox) injections - FDA-approved for severe axillary hyperhidrosis 1, 3, 4. This provides 3-9 months of efficacy 6.

Third-line: Oral glycopyrrolate 1-2 mg once or twice daily 1, 7, 3. Start at low doses and titrate based on response and tolerability 7.

Fourth-line: Local surgical options including curettage with scraper or liposuction 6

Fifth-line: Endoscopic thoracic sympathectomy (ETS) only after all other options have failed 3, 5

Alternative second-line option: Local microwave therapy for axillary hyperhidrosis 4

Palmar and Plantar Hyperhidrosis

First-line: Topical aluminum chloride 10-20% solution 3, 4, 5

Second-line: Oral glycopyrrolate 1-2 mg once or twice daily (preferred) or clonidine 0.1 mg twice daily 3. Glycopyrrolate offers low cost, convenience, and excellent safety with reasonable efficacy 3.

Third-line: Tap water iontophoresis - highly effective but requires initial investment and ongoing maintenance treatments 3, 5, 6. Adding anticholinergic substances to the water produces more rapid and longer-lasting therapeutic success 6.

Fourth-line: Botulinum toxin A injections - highly effective but expensive, requires repeat treatments every 3-6 months, and associated with pain and/or anesthesia-related complications 3, 4

Fifth-line: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 3, 5

Craniofacial Hyperhidrosis

First-line: Oral glycopyrrolate 1-2 mg once or twice daily 1, 2, 3 or topical glycopyrrolate 2, 4

Second-line: Botulinum toxin A injections using careful technique to avoid facial weakness 1, 2, 3

Third-line: ETS for severe refractory cases 3

Medication Dosing and Administration Details

Oral Glycopyrrolate

• Dosing: Start at 1-2 mg once or twice daily 1, 2, 3
• Administration: Give at least 1 hour before or 2 hours after meals, as high-fat meals substantially reduce absorption 7
• Titration: For pediatric patients, titrate over 4 weeks starting at 0.02 mg/kg three times daily, increasing in increments of 0.02 mg/kg every 5-7 days, not to exceed 0.1 mg/kg three times daily or 3 mg three times daily 7
• Common anticholinergic side effects: Dry mouth, blurred vision, urinary retention, constipation 1, 7
• Serious warnings: Monitor elderly patients closely for cognitive effects and fall risk 1. Contraindicated in patients with urinary retention problems, paralytic ileus, severe ulcerative colitis, or myasthenia gravis 7

Topical Aluminum Chloride

• Application: Apply to completely dry skin at bedtime 3, 4
• Concentration: 10-20% solutions 1, 2, 3
• Scalp considerations: May cause irritation or scaling on the scalp 1, 2. Check vitamin D levels in patients with thick scaling 1, 2. Use high-potency topical steroids if inflammation develops 1, 2.

Botulinum Toxin A

• Efficacy duration: 3-9 months for axillary hyperhidrosis 6; requires repeat injections every 3-6 months for palmoplantar hyperhidrosis 3
• FDA approval: Approved for severe axillary hyperhidrosis 1
• Craniofacial technique: Requires careful injection technique to avoid facial muscle weakness 1, 2

Critical Pitfalls to Avoid

• Failing to distinguish primary from secondary hyperhidrosis leads to inappropriate treatment and missed underlying conditions 1
• Overlooking medications as causes of secondary hyperhidrosis 1
• Ignoring nocturnal hyperhidrosis - this is almost always secondary and requires evaluation for serious underlying conditions including malignancy 1
• Using glycopyrrolate with high-fat meals substantially reduces drug absorption 7
• Inadequate monitoring for constipation with glycopyrrolate - assess within 4-5 days of initial dosing or dose increases 7, 8
• Exposure to high ambient temperatures while on anticholinergic therapy can cause heat prostration due to decreased sweating 1, 7, 8
• Prescribing ETS prematurely before exhausting conservative options, given the invasive nature and risk of compensatory hyperhidrosis 3, 5, 6

Special Populations

Pediatric Patients

Treatment approaches are similar to adults with specific dosing adjustments 7. Avoid tetracyclines in children younger than 9 years 9. Evaluate for precocious puberty in patients age 11 or younger with other suspicious physical examination findings 9.

Pregnant Patients

Avoid retinoids and hormonal agents during pregnancy 9. Topical treatments and procedural treatments should be considered first-line, with systemic agents as second-line 9.