Treatment of Hyperhidrosis
For primary focal hyperhidrosis, topical aluminum chloride (10-20%) is the first-line treatment for axillary, palmar, and plantar sites, while oral glycopyrrolate (1-2 mg twice daily) is first-line for craniofacial hyperhidrosis. 1, 2, 3
Initial Assessment and Site-Specific Approach
Before initiating treatment, evaluate for secondary causes including thyroid dysfunction, medication side effects, and check thyroid function, iron stores, vitamin D, and zinc levels 1. The Hyperhidrosis Disease Severity Scale (HDSS) should guide treatment intensity: score of 2 indicates mild disease, while 3-4 indicates severe disease requiring more aggressive intervention 4, 3.
Axillary Hyperhidrosis Treatment Algorithm
Mild Disease (HDSS Score 2)
- First-line: Topical aluminum chloride 10-20% solution applied nightly to dry skin 2, 4, 3
- Second-line: OnabotulinumtoxinA (Botox) injections if aluminum chloride fails 1, 2, 3
- Third-line: Oral glycopyrrolate 1-2 mg once or twice daily 2, 3
- Fourth-line: Local surgical options including curettage or liposuction 2, 5
- Fifth-line: Endoscopic thoracic sympathectomy only after all other options exhausted 2, 4
Severe Disease (HDSS Score 3-4)
- First-line (dual approach): Both topical aluminum chloride AND botulinum toxin A simultaneously 4
- Botulinum toxin provides 3-6 months of efficacy but requires repeated treatments 2, 5
- Microwave thermolysis is a newer option for refractory axillary cases 3
Palmar and Plantar Hyperhidrosis Treatment Algorithm
Mild Disease (HDSS Score 2)
- First-line: Topical aluminum chloride 10-20% 2, 4
- Second-line: Oral glycopyrrolate 1-2 mg once or twice daily (preferred over clonidine 0.1 mg twice daily due to better safety profile and lower cost) 2
- Third-line: Tap water iontophoresis, though initial cost and time commitment are high 2, 5
- Fourth-line: Botulinum toxin injections (expensive, painful, requires anesthesia, needs repeat every 3-6 months) 2
- Fifth-line: Endoscopic thoracic sympathectomy for palmar only (NOT recommended for plantar due to anatomic risks) 2, 4
Severe Disease (HDSS Score 3-4)
- First-line (triple approach): Topical aluminum chloride, botulinum toxin A, AND iontophoresis simultaneously 4
- Adding anticholinergic substances to iontophoresis water produces faster and longer-lasting results 5
Craniofacial Hyperhidrosis Treatment Algorithm
First-line: Oral glycopyrrolate 1-2 mg twice daily is preferred over topical treatments due to scalp irritation risk 1, 2, 3
- Side effects include dry mouth, blurred vision, urinary retention, and constipation 1
- Alternative oral option: Clonidine 0.1 mg twice daily 2
Second-line: Topical glycopyrrolate for localized areas 3
Third-line: OnabotulinumtoxinA injections (may cause temporary weakness in adjacent muscles depending on injection site) 1, 2
Last resort: Endoscopic thoracic sympathectomy for severe refractory cases 2
Important Medication Side Effects and Monitoring
Anticholinergic medications (glycopyrrolate): Monitor for dry mouth, blurred vision, urinary retention, and constipation 1. Follow-up every 3-6 months to adjust treatment 1.
Topical aluminum chloride: May cause irritation or scaling, particularly on the scalp 1. If inflammation develops, use topical high-potency steroids 1.
Botulinum toxin: Temporary weakness in adjacent muscles is possible; palmar injections are particularly painful and may require nerve blocks 2, 5.
Lifestyle Modifications
- Avoid triggers: spicy foods, caffeine, and alcohol 1
- Wear moisture-wicking materials and appropriate headwear 1
- Maintain regular scalp hygiene to prevent secondary complications 1
- Weight loss may improve symptoms in obese patients, though evidence is limited 6
Critical Pitfall to Avoid
Never perform incision and drainage for hyperhidrosis lesions—this has nearly 100% recurrence rates 6. Instead, use deroofing technique with punch tool or electrosurgery for acute lesions, which has only 4-17% recurrence 6.