What are the treatment options for hyperhidrosis?

Treatment for Hyperhidrosis

Start with topical aluminum chloride 10-20% solution as first-line therapy for axillary and palmoplantar hyperhidrosis, while topical glycopyrrolate should be used first for craniofacial sweating. 1, 2

Initial Assessment

Before initiating treatment, evaluate for secondary causes that may be driving the excessive sweating:

• Check thyroid function tests to exclude hyperthyroidism 1
• Review all current medications that may cause sweating as a side effect 1
• Assess iron stores, vitamin D, and zinc levels 1

Treatment Algorithm by Anatomic Location

Axillary Hyperhidrosis

First-line: Topical aluminum chloride 10-20% solution applied to dry skin at bedtime 1, 3, 2, 4

• This remains the most cost-effective and accessible initial treatment 3, 4
• Note: Can cause skin irritation and has a short half-life requiring frequent reapplication 5

Second-line: OnabotulinumtoxinA (Botox) injections into the axillae 1, 3, 2

• Provides 3-6 months of relief but requires repeated treatments 1
• May cause temporary weakness in adjacent muscles depending on injection site 1
• High efficacy but expensive and requires regular maintenance 3

Third-line: Oral anticholinergic medications 3, 2

• Glycopyrrolate 1-2 mg once or twice daily is preferred 3
• Alternative: Clonidine 0.1 mg twice daily 3

Fourth-line: Local surgical options including curettage, liposuction, or microwave thermolysis 3, 2, 4

Fifth-line: Endoscopic thoracic sympathectomy (ETS) 3, 2

• Reserved for severe refractory cases due to risk of compensatory hyperhidrosis and other complications 5

Palmar and Plantar Hyperhidrosis

First-line: Topical aluminum chloride 10-20% solution 3, 2, 4

Second-line: Oral anticholinergic medications 3

• Glycopyrrolate 1-2 mg once or twice daily is preferred over clonidine 0.1 mg twice daily 3
• This recommendation prioritizes low cost, convenience, and emerging safety data 3

Third-line: Tap water iontophoresis 3, 5, 4

• High efficacy for palmoplantar hyperhidrosis 3, 4
• Requires initial investment in equipment and ongoing maintenance treatments 3, 5
• Adding anticholinergic substances to the water produces more rapid and longer-lasting results 4

Fourth-line: Botulinum toxin injections 3, 2

• High efficacy but expensive, requires repeat treatments every 3-6 months 3
• Associated with significant pain and may require anesthesia 3

Fifth-line: ETS for palmar hyperhidrosis only 3, 2

• Not recommended for plantar hyperhidrosis due to anatomic risks 3
• Risk of compensatory hyperhidrosis, Horner syndrome, and neuralgia 5

Craniofacial Hyperhidrosis

First-line: Oral anticholinergic medications 3, 2

• Either glycopyrrolate or clonidine 3
• Topical glycopyrrolate is also first-line for craniofacial sweating 2

Second-line: Botulinum toxin injections 3, 2

• May be useful in selected cases 3

Third-line: ETS for severe refractory craniofacial hyperhidrosis 3

Important Considerations for Glycopyrrolate Use

When prescribing oral glycopyrrolate (FDA-approved for pediatric drooling but used off-label for hyperhidrosis):

• Administer at least 1 hour before or 2 hours after meals as high-fat food significantly reduces absorption 6
• Start at low doses and titrate gradually based on therapeutic response and tolerability 6
• Most common adverse effects: dry mouth (40%), vomiting (40%), constipation (35%), flushing (30%), and nasal congestion (30%) 6

Critical Contraindications for Glycopyrrolate

Do not use glycopyrrolate in patients with: 6

• Glaucoma
• Paralytic ileus
• Unstable cardiovascular status in acute hemorrhage
• Severe ulcerative colitis or toxic megacolon
• Myasthenia gravis

Key Safety Warnings

• Monitor for constipation, especially within 4-5 days of initial dosing or dose increases 6
• Avoid exposure to high ambient temperatures as anticholinergics reduce sweating and can cause heat prostration, fever, and heat stroke 6
• May cause drowsiness or blurred vision affecting ability to operate machinery 6

Common Pitfalls to Avoid

• Do not use incision and drainage for hyperhidrosis lesions due to nearly 100% recurrence rate 1
• Avoid simple excision without considering deroofing techniques for chronic lesions 1
• Do not proceed directly to surgery without exhausting conservative treatment options first 5, 4
• Counsel patients about compensatory hyperhidrosis before ETS, as some patients find this worse than the original condition 5