Treatment for Hyperhidrosis (Sweaty Hands)

Start with topical aluminum chloride solution as first-line treatment for palmar hyperhidrosis, applying it at night to dry hands. 1, 2

Initial Treatment Approach

Apply 20% aluminum chloride hexahydrate solution to completely dry palms at bedtime 1, 3
Wash off in the morning to minimize skin irritation 3
This remains the most cost-effective initial treatment despite newer alternatives 2, 3
Expect skin irritation as the main limitation—this can be managed by reducing application frequency 3, 4

Glycopyrrolate 1-2 mg once or twice daily is preferred over other systemic options for palmar hyperhidrosis when topical treatment fails 2
This represents a practical second-line choice due to low cost, convenience, and emerging safety data 2
Clonidine 0.1 mg twice daily is an alternative if glycopyrrolate is not tolerated 2
Systemic anticholinergics reduce sweating but dose-limiting side effects (dry mouth, blurred vision, urinary retention) often restrict their use 3, 4

Tap water iontophoresis is highly effective for palmar hyperhidrosis but requires significant time commitment 2, 3
Treatment involves placing hands in water trays with electrical current applied for 20-30 minutes, typically 3 times weekly initially, then maintenance sessions 3, 4
Adding anticholinergic substances to the water produces more rapid and longer-lasting results 3
This method has no long-term adverse effects but requires ongoing maintenance treatments 4
The high initial cost and inconvenience place this after oral medications despite excellent efficacy 2

OnabotulinumtoxinA injections are highly effective for palmar hyperhidrosis but involve significant practical limitations 1, 2
Treatment must be repeated every 3-6 months to maintain benefit 2, 4
The procedure is painful and may require nerve blocks or general anesthesia for hand injections, which adds complexity and risk 2
Cost remains substantial as this is not a one-time treatment 2
Despite these drawbacks, efficacy is excellent when other treatments fail 2, 3

Endoscopic thoracic sympathectomy (ETS) should only be considered for severe palmar hyperhidrosis unresponsive to all conservative measures 2, 4
Patients must be counseled about compensatory hyperhidrosis (sweating in other body areas), which occurs in the majority of patients and may be worse than the original problem 4
Other surgical complications include Horner syndrome, neuralgia, and gustatory sweating 4
The highly invasive nature and significant complication profile make this a last resort 3, 4

Do not skip directly to invasive treatments without trying topical and oral therapies first—the treatment ladder exists for good reason 2, 5
Do not apply aluminum chloride to wet or damp hands, as this dramatically increases irritation without improving efficacy 3
Do not recommend ETS without extensive counseling about compensatory hyperhidrosis, which patients often find more distressing than palmar sweating 4
Avoid prescribing systemic anticholinergics at doses that cause intolerable side effects—start low and titrate carefully 3, 4

Move to the next treatment tier when the current therapy fails to adequately control symptoms after an appropriate trial (typically 2-4 weeks for topical agents, 4-6 weeks for oral medications) 5
Consider combination therapy in severe cases, such as oral glycopyrrolate plus topical aluminum chloride 5
Assess impact on quality of life using the Hyperhidrosis Disease Severity Scale to guide treatment intensity 1