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

Treatment of Excessive Sweating (Hyperhidrosis)

Start with topical aluminum chloride solution as first-line treatment for most cases of primary focal hyperhidrosis affecting the axillae, palms, or soles, but use topical glycopyrrolate for craniofacial sweating. 1

Exclude Secondary Causes First

Before treating as primary hyperhidrosis, systematically screen for underlying conditions that cause excessive sweating, as this is the most critical diagnostic error to avoid 2:

• Order laboratory workup including: complete blood count, comprehensive metabolic panel, thyroid function tests (TSH, free T4), hemoglobin A1c, serum calcium, vitamin D, and iron studies 2
• Screen specifically for: hyperthyroidism (Graves disease), diabetes mellitus, pheochromocytoma (episodic sweating with headache/palpitations), medications (sympathomimetics, decongestants, anticholinergics), menopause, infections, and spinal cord injury above T6 3, 2
• If secondary cause identified: treat the underlying condition rather than the sweating symptom 4, 5

Stepwise Treatment Algorithm for Primary Hyperhidrosis

First-Line Topical Therapy

For axillary, palmar, or plantar hyperhidrosis:

• Apply aluminum chloride solution (typically 20% concentration) at bedtime to completely dry skin 1, 6
• Wash off in the morning to minimize skin irritation 6
• Limitation: Short half-life requiring frequent application, and can cause skin irritation 4

For craniofacial hyperhidrosis:

• Use topical glycopyrrolate as the first-line treatment instead of aluminum chloride 1

Second-Line Options (When Topical Fails)

Botulinum toxin A (onabotulinumtoxinA) injections:

• Consider as first- or second-line for axillary, palmar, plantar, or craniofacial hyperhidrosis 1
• Provides 6-8 months of symptom relief 4, 7
• Efficacy rates exceed 90-95% 5
• Limitation: Requires repeat injections every 6-8 months for maintenance 4

Iontophoresis (tap water):

• Use specifically for palmar and plantar hyperhidrosis 1, 6
• Simple, well-tolerated method without long-term adverse effects 4
• Adding anticholinergic substances to water produces more rapid and longer-lasting results 6
• Limitation: Requires long-term maintenance treatments to remain symptom-free 4

Third-Line Systemic Therapy

Oral anticholinergics (e.g., oral glycopyrronium):

• Use as adjuncts in severe cases when topical and injection therapies fail 1, 7
• Major limitation: The dose required to control sweating often causes significant adverse effects (dry mouth, blurred vision, urinary retention, constipation), limiting effectiveness 4, 6

Fourth-Line Invasive Options

Local microwave therapy:

• Newer treatment option specifically for axillary hyperhidrosis 1

Surgical interventions (only after conservative methods fail):

• Curettage with scraper and liposuction: Reliable and safe for axillary hyperhidrosis 6
• Endoscopic thoracic sympathectomy: Consider only in severe cases unresponsive to all other treatments 1, 4
• Critical warning: Sympathectomy carries substantial complications including compensatory hyperhidrosis (sweating elsewhere), gustatory hyperhidrosis, Horner syndrome, and neuralgia—some patients find these worse than the original condition 4
• Axillary sweat gland excision: Can cause unsightly scarring 4

Special Clinical Situations

Exercise-induced or heat-related sweating with dehydration:

• Provide oral carbohydrate-electrolyte solutions rather than water alone, with volume consumed exceeding sweat losses 3

If heat stroke suspected (altered consciousness, confusion, seizures, temperature >40°C/104°F):

• Begin immediate cold water immersion up to the chin while activating EMS—this is the single most important intervention and should not be delayed 3

Assessment Tool

Use the Hyperhidrosis Disease Severity Scale to grade sweating tolerability and guide treatment intensity 1:

• This validated survey measures impact on quality of life and helps determine when to escalate therapy 1