What treatment options are available for an otherwise healthy adult patient with axillary hyperhidrosis?

Treatment of Axillary Hyperhidrosis

For an otherwise healthy adult with axillary hyperhidrosis, begin with topical aluminum chloride solution as first-line therapy, escalate to botulinum toxin A injections if topical treatment fails, and reserve surgical options only after conservative measures prove inadequate. 1, 2, 3

First-Line Treatment: Topical Aluminum Chloride

• Topical aluminum chloride solution is the initial treatment of choice for primary axillary hyperhidrosis, with established efficacy and minimal side effects 1, 2, 3
• This approach should be attempted before considering more invasive or expensive interventions 1, 3

Second-Line Treatment: Botulinum Toxin A Injections

• Botulinum toxin A (onabotulinumtoxinA) is recommended as first- or second-line treatment for axillary hyperhidrosis when topical therapy fails 2, 3
• A dose of 200 units injected intradermally into the affected axilla reduces sweat production from a baseline mean of 192 mg/minute to 24 mg/minute within 2 weeks 4
• The therapeutic effect lasts 3-9 months, requiring repeat injections for sustained benefit 1, 4
• At 24 weeks post-injection, sweat production remains significantly reduced (67 mg/minute versus 192 mg/minute at baseline) 4
• Treatment is well-tolerated, with 98% of patients reporting they would recommend this therapy to others 4
• This option provides excellent efficacy with a favorable safety profile, though cost and need for repeated treatments are considerations 3

Third-Line Treatment: Oral Anticholinergics

• Systemic anticholinergic medications (glycopyrrolate 1-2 mg once or twice daily preferred) serve as useful adjuncts in severe cases when topical and injection therapies fail 2, 3
• These medications are often limited by their adverse effect profile, including dry mouth, blurred vision, urinary retention, and constipation 1, 3

Fourth-Line Treatment: Local Surgical Options

• Curettage with a scraper and liposuction are reliable and safe surgical treatments for axillary hyperhidrosis 1
• Local microwave therapy (MiraDry®) is a newer treatment option for axillary hyperhidrosis, though complications including dermal detachment, subcutaneous collections, dermal thickening, and retractile scars have been reported 5, 2
• These procedures should only be considered after conservative methods have failed 1, 2

Fifth-Line Treatment: Endoscopic Thoracic Sympathectomy

• Endoscopic thoracic sympathectomy (ETS) should be reserved for severe cases of axillary hyperhidrosis that have not responded to topical, medical, or local surgical therapies 2, 3
• This highly invasive procedure should only be considered in well-justified cases due to its irreversible nature and potential for compensatory hyperhidrosis 1, 3

Important Clinical Considerations

• Before initiating treatment, exclude secondary causes of hyperhidrosis including hyperthyroidism, pheochromocytoma, medications, menopause, and infections 6
• The Hyperhidrosis Disease Severity Scale is a validated survey that grades the tolerability of sweating and its impact on quality of life, and can guide treatment intensity 2
• Primary hyperhidrosis is bilaterally symmetric and focal, affecting specific areas without an underlying medical condition 2
• Patients with hyperhidrosis often suffer enormous psychosocial stress with restrictions in both private and professional lives, justifying aggressive treatment 1

Treatment Algorithm Summary

1. Start: Topical aluminum chloride solution
2. If inadequate response: Botulinum toxin A injections (200 units per axilla)
3. If still inadequate: Oral glycopyrrolate 1-2 mg once or twice daily
4. If refractory: Local surgical options (curettage, liposuction, or microwave therapy)
5. Last resort only: Endoscopic thoracic sympathectomy