How is hyperhidrosis treated?

Treatment of Hyperhidrosis

Start with topical aluminum chloride as first-line therapy for axillary and palmoplantar hyperhidrosis, then escalate systematically based on anatomic location and treatment response. 1, 2, 3

Initial Assessment and First-Line Treatment

Topical Antiperspirants

• Apply aluminum chloride solution as initial treatment for most cases of primary focal hyperhidrosis affecting axillae, palms, and soles. 1, 3
• For craniofacial hyperhidrosis specifically, use topical glycopyrrolate as first-line therapy instead. 3
• Topical agents are quick to apply but may cause skin irritation and have short duration of action. 4

Anatomic Location-Specific Treatment Algorithms

Axillary Hyperhidrosis (Underarm Sweating)

Follow this stepwise escalation:

1. First-line: Topical aluminum chloride 1, 3
2. Second-line: Botulinum toxin injections (onabotulinumtoxinA) 1, 3
3. Third-line: Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily) 1
4. Fourth-line: Local surgical excision, curettage, or liposuction 1, 2
5. Fifth-line: Endoscopic thoracic sympathectomy (ETS) 1

Alternative option: Microwave thermolysis is a newer treatment specifically for axillary hyperhidrosis. 3

Palmar and Plantar Hyperhidrosis (Hands and Feet)

1. First-line: Topical aluminum chloride 1, 3
2. Second-line: Oral anticholinergics—glycopyrrolate 1-2 mg once or twice daily is preferred over clonidine 0.1 mg twice daily due to better tolerability 1
   • Monitor for side effects including dry mouth, blurred vision, and urinary retention 5
3. Third-line: Iontophoresis—pass mild electrical current through water and skin surface 5, 1
   • Requires 3-4 sessions per week initially, then 1-2 maintenance sessions weekly 5
   • High efficacy but requires significant time commitment 1
4. Fourth-line: Botulinum toxin injections 5, 1
   • Use nerve blocks before injection to minimize pain during administration 5
   • May cause temporary weakness in hand muscles 5
   • Expensive and requires repeat injections every 3-6 months 1, 4
5. Fifth-line: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 1

Craniofacial Hyperhidrosis (Face and Scalp)

1. First-line: Oral anticholinergics (glycopyrrolate or clonidine) 1
2. Second-line options: Topical glycopyrrolate or botulinum toxin injections 1, 3
3. Last resort: ETS for severe cases 1

Adjunctive Measures

Behavioral Modifications

• Avoid known triggers that worsen sweating 5
• Wear moisture-wicking materials 5
• These measures provide supportive benefit but are insufficient as monotherapy 5

Critical Warnings and Pitfalls

Surgical Considerations

• Endoscopic thoracic sympathectomy should only be considered as last resort when all conservative treatments have failed or are intolerable. 2, 3
• Patients must accept compensatory hyperhidrosis (sweating in other body areas) as a potential permanent complication before proceeding with sympathectomy. 2, 4
• Complications of sympathectomy include compensatory and gustatory hyperhidrosis, Horner syndrome, and neuralgia—some patients find these worse than the original condition. 4

Medication Monitoring

• When using oral anticholinergics, monitor closely for anticholinergic side effects: dry mouth, blurred vision, urinary retention, and constipation. 5, 1
• Systemic medications may require doses that cause significant adverse effects, limiting their long-term usefulness. 4

Treatment Duration

• Botulinum toxin is not permanent—patients require repeat injections every 3-8 months to maintain benefits. 1, 4
• Iontophoresis requires ongoing maintenance treatments to keep patients symptom-free. 4