What treatments are available for hyperhidrosis (excessive sweating)?

Treatment Options for Hyperhidrosis (Excessive Sweating)

Start with topical aluminum chloride 20% solution applied nightly to dry skin as first-line therapy for axillary, palmar, and plantar hyperhidrosis. 1, 2

Stepwise Treatment Algorithm by Location

Axillary (Underarm) Hyperhidrosis

First-line: Apply aluminum chloride 20% solution to completely dry skin at bedtime, wash off in the morning; repeat nightly until sweating is controlled, then reduce to 1-2 times weekly for maintenance 1, 2, 3

Second-line: OnabotulinumtoxinA (Botulinum toxin) injections provide 3-9 months of relief and are FDA-approved for this indication 1, 2, 3

Third-line: Oral anticholinergics—specifically glycopyrrolate 1-2 mg once or twice daily 1, 2

Fourth-line: Local surgical excision, curettage with scraper, or liposuction of axillary sweat glands 1, 3

Fifth-line: Endoscopic thoracic sympathectomy (ETS) only after all other options have failed 1, 2

Palmar and Plantar (Hands and Feet) Hyperhidrosis

First-line: Aluminum chloride 20% solution applied as described above 1, 2

Second-line: Oral glycopyrrolate 1-2 mg once or twice daily is preferred over clonidine 0.1 mg twice daily due to better tolerability and emerging safety data 1

Third-line: Tap water iontophoresis—immerse affected areas in water with electrical current for 20-30 minutes, 3-4 times weekly initially, then maintenance sessions 1, 2, 3, 4

Fourth-line: Botulinum toxin injections (requires repeat treatments every 3-6 months and involves significant injection pain requiring anesthesia) 1, 2

Fifth-line: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 1, 2

Craniofacial (Face and Scalp) Hyperhidrosis

First-line: Topical glycopyrrolate is specifically recommended for facial sweating 2

Alternative first-line: Oral glycopyrrolate 1-2 mg once or twice daily or clonidine 0.1 mg twice daily 1

Second-line: Botulinum toxin injections to affected facial areas 1, 2

Third-line: ETS only for severe, refractory cases 1

Critical Treatment Principles

Before Starting Any Treatment

Rule out secondary causes first—obtain complete blood count, comprehensive metabolic panel, thyroid function tests (TSH, free T4), hemoglobin A1c, and review all medications for anticholinergics, stimulants, dopamine-reuptake inhibitors, and diuretics that impair thermoregulation 5

Screen specifically for hyperthyroidism, diabetes, pheochromocytoma, carcinoid syndrome, malignancies (lymphoma, leukemia), menopause, heart failure, chronic kidney disease, sleep apnea, and autonomic dysfunction 5

Aluminum Chloride Application Technique

Apply only to completely dry skin (critical for efficacy and to prevent irritation); cover with plastic wrap overnight if tolerated; wash off in morning; expect skin irritation as the main limiting factor 1, 2, 3

Botulinum Toxin Practical Details

Expect 50-100 injection sites per treatment area; effects last 3-9 months; axillary treatment is FDA-approved and best tolerated; palmar/plantar injections require nerve blocks or general anesthesia due to pain 1, 2, 3

Oral Anticholinergic Considerations

Glycopyrrolate is preferred over other anticholinergics due to better side effect profile; common adverse effects include dry mouth, blurred vision, urinary retention, and constipation that limit dosing 1, 2, 4

Iontophoresis Protocol

Use tap water with 20-30 minute sessions; add anticholinergic substances to water for faster and longer-lasting results; requires ongoing maintenance treatments indefinitely; high initial cost and time commitment but excellent long-term safety 1, 3, 4

Common Pitfalls to Avoid

Never proceed to surgery without exhausting all conservative options first—compensatory hyperhidrosis (sweating in new body areas) occurs in up to 80% of ETS patients and may be worse than the original condition 1, 4

Do not assume all hyperhidrosis is primary—systematically exclude thyroid dysfunction and diabetes, which are readily treatable causes 5

Avoid prescribing systemic anticholinergics as first-line therapy—the doses needed to control sweating typically cause intolerable side effects (dry mouth, constipation, urinary retention, blurred vision) 1, 2, 4

Do not overlook medication-induced hyperhidrosis—review the complete medication list for anticholinergics, stimulants (ADHD medications), diuretics, and oral retinoids 5