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

Treatment of Hyperhidrosis

For primary hyperhidrosis, start with topical aluminum chloride 10-20% for axillary, palmar, and plantar sweating, or topical glycopyrrolate for craniofacial sweating, then escalate to botulinum toxin injections if first-line therapy fails. 1, 2

Initial Assessment

Before initiating treatment, you must distinguish primary from secondary hyperhidrosis, as this fundamentally changes management 1, 2:

• Primary hyperhidrosis presents as bilateral, symmetric, focal excessive sweating affecting axillae, palms, soles, or craniofacial regions without an underlying cause 1, 2
• Secondary hyperhidrosis may be focal or generalized and requires identification and treatment of the underlying condition 2

Red Flags Requiring Further Workup

• Nocturnal sweating almost always indicates secondary hyperhidrosis and mandates evaluation for sleep disorders, cardiovascular disease, endocrine disorders, or malignancy 1
• Unilateral or asymmetric sweating suggests secondary causes 2
• Associated symptoms including thyroid dysfunction, sleep disturbances, orthostatic symptoms, or polyuria 1

Essential Evaluation Steps

Medication review is critical as many drugs cause secondary hyperhidrosis, including anticholinesterases, selective serotonin reuptake inhibitors, and others 1

Physical examination should assess sweating distribution, check orthostatic blood pressure, evaluate for thyroid abnormalities and peripheral edema, and inspect the scalp for scaling or inflammation if craniofacial involvement exists 1

Laboratory testing for suspected secondary hyperhidrosis includes complete blood count, comprehensive metabolic panel, thyroid function tests, hemoglobin A1c, iron studies, vitamin D, zinc levels, and serum calcium 1

Treatment Algorithm by Location

Axillary Hyperhidrosis

First-line: Topical aluminum chloride 10-20% applied at bedtime to dry skin 3, 2, 4

• Apply a small amount to underarms at bedtime, rinse in the morning with abundant water, then apply regular antiperspirant 3
• Use for several consecutive nights until excessive perspiration is controlled, then apply twice weekly for maintenance 3
• This remains the method of choice despite newer alternatives 4

Second-line: OnabotulinumtoxinA injections, which are FDA-approved for severe axillary hyperhidrosis 1, 2

• Provides efficacy for 3-9 months 4
• Consider as first- or second-line treatment depending on severity 2

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

• Reserve for severe cases when topical treatments and botulinum toxin fail 2
• Monitor for anticholinergic side effects: dry mouth, blurred vision, urinary retention, constipation 1
• Elderly patients require close monitoring for cognitive effects and fall risk 1

Alternative options: Microwave thermolysis for refractory cases, or surgical interventions (curettage, liposuction) only after conservative methods fail 4, 2

Palmar and Plantar Hyperhidrosis

First-line: Tap water iontophoresis 2, 4, 5

• Simple, well-tolerated method without long-term adverse effects 5
• Adding anticholinergic substances to water produces more rapid and longer-lasting therapeutic success 4
• Requires long-term maintenance treatments to keep patients symptom-free 5

Second-line: Topical aluminum chloride 10-20% 2, 4

Third-line: Botulinum toxin A injections 2, 4

• Effective but requires repeat injections every 6-8 months 5

Last resort: Endoscopic thoracic sympathectomy only for severe cases unresponsive to all other therapies 2, 5

• Highly invasive with significant complications including compensatory hyperhidrosis, gustatory hyperhidrosis, Horner syndrome, and neuralgia 5
• Some patients find complications worse than the original condition 5

Craniofacial Hyperhidrosis

First-line: Topical glycopyrrolate or oral glycopyrrolate 1-2 mg once or twice daily 1, 2, 6

• Topical glycopyrronium is supported by at least 8 clinical trials enrolling more than 2000 patients 6
• Topical formulations avoid systemic anticholinergic effects 6

Second-line: Botulinum toxin A injections 1, 2

• Requires careful injection technique to avoid facial weakness 1

Caution: 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

Critical Pitfalls to Avoid

Do not treat without distinguishing primary from secondary hyperhidrosis - this leads to inappropriate treatment and missed underlying conditions 1

Do not overlook medications as causes - review all medications before initiating treatment for presumed primary hyperhidrosis 1

Do not ignore nocturnal sweating - this almost always represents secondary hyperhidrosis requiring evaluation for serious conditions including malignancy 1

Do not rush to surgery - surgical options should only be considered after all conservative methods have failed due to the invasive nature and potential for severe complications 4, 5

Do not use oral anticholinergics as first-line therapy - the dose required to control sweating often causes intolerable adverse effects 5