What are the treatment options for hyperhidrosis?

Treatment for Hyperhidrosis

For primary focal hyperhidrosis, begin with topical aluminum chloride 10-20% solution as first-line therapy, escalating to botulinum toxin injections for axillary disease or oral glycopyrrolate for craniofacial involvement when topical therapy fails. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, evaluate for secondary causes of hyperhidrosis by checking:

• Thyroid function tests to exclude hyperthyroidism 1
• Medication review for drugs causing excessive sweating 1
• Iron stores, vitamin D, and zinc levels 1

Use the Hyperhidrosis Disease Severity Scale to grade severity and guide treatment intensity 2.

Treatment Algorithm by Anatomic Location

Axillary Hyperhidrosis

First-line therapy:

• Topical aluminum chloride 10-20% solution applied to dry skin at bedtime 1, 2, 3
• Note: May cause scalp irritation or scaling if used on the head 1

Second-line therapy:

• OnabotulinumtoxinA (Botox) injections into affected areas 1, 2
• Provides 3-6 months of relief but requires repeated treatments 3, 4
• May cause temporary weakness in adjacent muscles depending on injection site 1

Third-line therapy:

• Oral glycopyrrolate 1-2 mg twice daily 3
• Common side effects include dry mouth, blurred vision, urinary retention, and constipation 1, 5
• Contraindicated in glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, and myasthenia gravis 5

Fourth-line therapy:

• Local microwave therapy for axillary disease 2
• Local surgical excision or curettage 3, 6

Fifth-line therapy:

• Endoscopic thoracic sympathectomy (ETS) only after all other options exhausted 3
• Risk of compensatory hyperhidrosis, gustatory sweating, Horner syndrome, and neuralgia 4

Palmar and Plantar Hyperhidrosis

First-line therapy:

• Topical aluminum chloride 10-20% solution 2, 3

Second-line therapy:

• Oral glycopyrrolate 1-2 mg once or twice daily (preferred) or clonidine 0.1 mg twice daily 3
• Glycopyrrolate offers better efficacy with reasonable safety profile 3

Third-line therapy:

• Tap water iontophoresis 2, 3, 6
• High efficacy but requires ongoing maintenance treatments 4, 6
• Adding anticholinergic substances to water produces more rapid and longer-lasting results 6

Fourth-line therapy:

• Botulinum toxin injections 3
• Highly effective but expensive, painful, and requires repeat treatments every 3-6 months 3, 4

Fifth-line therapy:

• ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 3

Craniofacial Hyperhidrosis

First-line therapy:

• Topical glycopyrrolate 1% solution/gel applied twice daily 2
• Oral glycopyrrolate 1-2 mg once or twice daily or clonidine 0.1 mg twice daily 3

Second-line therapy:

• OnabotulinumtoxinA injections 1, 3

Third-line therapy:

• ETS for severe refractory cases 3

Adjunctive Measures

All patients should receive counseling on:

• Avoiding triggers: spicy foods, caffeine, alcohol 1
• Wearing moisture-wicking materials and appropriate headwear 1
• Maintaining regular scalp hygiene to prevent secondary complications 1
• Avoiding exposure to hot environments, especially when on anticholinergic medications 5

Special Considerations

Glycopyrrolate dosing specifics:

• Administer at least 1 hour before or 2 hours after meals (high-fat meals reduce absorption) 5
• Start at low dose and titrate gradually over weeks based on response and tolerability 5
• Monitor closely for constipation (most common side effect requiring discontinuation) 5
• Watch for urinary retention, particularly in patients with neurologic conditions 5

Monitoring:

• Regular follow-up every 3-6 months to assess treatment response and medication side effects 1
• Reassess severity using validated scales to guide treatment adjustments 2

Common Pitfalls to Avoid

• Do not use incision and drainage for hyperhidrosis lesions (nearly 100% recurrence rate) 7
• Avoid simple excision without considering deroofing techniques for chronic lesions 7
• Do not escalate methylprednisolone above 2 mg/kg/day (no additional benefit) 7
• Recognize that single environmental control interventions (like dust mite covers alone) are ineffective; multiple strategies may be needed 7