What are the treatment options for hyperhidrosis?

Treatment for Hyperhidrosis

Start with topical aluminum chloride 10-20% solution as first-line therapy for axillary hyperhidrosis, applying it to completely dry skin at bedtime and washing it off in the morning. 1

Initial Assessment

Before initiating treatment, evaluate for secondary causes of hyperhidrosis by checking: 1

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

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, 4

Second-line therapy: OnabotulinumtoxinA (Botox) injections into the affected areas 1, 2, 3, 4

• Provides 3-6 months of relief but requires repeated treatments
• May cause temporary weakness in adjacent muscles depending on injection site
• Administered at the dermal-subcutaneous junction 3

Third-line therapy: Oral anticholinergic medications 2, 4

• Glycopyrrolate 1-2 mg once or twice daily (preferred) 2, 5
• Clonidine 0.1 mg twice daily (alternative) 2

Fourth-line therapy: Local surgical procedures including excision, curettage, liposuction, or combination techniques 2, 3

Fifth-line therapy: Endoscopic thoracic sympathectomy (ETS) - reserved for severe, refractory cases 2, 3

Palmar and Plantar Hyperhidrosis

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

Second-line therapy: Oral anticholinergic medications due to low cost, convenience, and reasonable efficacy 2

• Glycopyrrolate 1-2 mg once or twice daily (preferred) 2, 5
• Clonidine 0.1 mg twice daily (alternative) 2

Third-line therapy: Iontophoresis (tap water or with anticholinergic additives) 2, 3, 4, 6

• High efficacy but requires initial investment and ongoing maintenance treatments
• Adding anticholinergic substances to water produces more rapid and longer-lasting therapeutic success 6

Fourth-line therapy: Botulinum toxin injections 2, 3, 4

• High efficacy but expensive, requires repetition every 3-6 months
• Associated with pain and potential anesthesia-related complications

Fifth-line therapy: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 2, 3

Craniofacial Hyperhidrosis

First-line therapy: Oral anticholinergic medications 2, 4

• Glycopyrrolate 1-2 mg once or twice daily 2
• Clonidine 0.1 mg twice daily 2

Alternative options: Topical glycopyrrolate for localized craniofacial sweating 4

Second-line therapy: Botulinum toxin injections for focal areas 2, 3

Third-line therapy: ETS for severe, refractory craniofacial hyperhidrosis 2

Systemic Anticholinergic Therapy Details

When prescribing glycopyrrolate oral solution: 5

• Administer at least 1 hour before or 2 hours after meals (high-fat meals substantially reduce bioavailability)
• Start at low doses and titrate gradually over weeks based on therapeutic response and tolerability
• Common adverse reactions include dry mouth (40%), vomiting (40%), constipation (35%), flushing (30%), nasal congestion (30%), and urinary retention (15%)

Critical 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

Monitor for constipation closely, particularly within 4-5 days of initiating or increasing anticholinergic therapy 5

Warn patients about heat intolerance when using anticholinergic medications - these drugs reduce sweating and can lead to heat exhaustion or heat stroke in hot environments 5

Screen for contraindications before prescribing anticholinergics, including glaucoma, paralytic ileus, severe ulcerative colitis, myasthenia gravis, and urinary retention 5

Emerging Treatment Options

Microwave thermolysis is a newer FDA-approved treatment option specifically for axillary hyperhidrosis 3, 4

Energy-delivering devices including lasers, ultrasound technology, and fractional microneedle radiofrequency may reduce focal sweating 3

Surgical Considerations

Surgery should only be considered when conservative treatments have failed or are intolerable 3, 4, 7

Compensatory hyperhidrosis is a potential complication of sympathectomy that patients must accept before proceeding, as some may find it worse than the original condition 2, 7