What are the treatment options for a patient with hyperhidrosis?

Treatment of Hyperhidrosis

First-Line Treatment: Topical Aluminum Chloride

Start with topical aluminum chloride 10-20% solution as first-line therapy for axillary hyperhidrosis, which is the most common presentation. 1, 2, 3

• Apply aluminum chloride solution to completely dry skin at bedtime, then wash off in the morning to minimize irritation 2, 3
• This remains the gold standard initial treatment across all anatomic sites except craniofacial hyperhidrosis 2, 3
• Be aware that aluminum chloride may cause scalp irritation or scaling if used on the head 1
• For craniofacial hyperhidrosis specifically, skip topical aluminum chloride and proceed directly to oral anticholinergics 2

Second-Line Treatment: Botulinum Toxin Injections

If topical aluminum chloride fails after 4-6 weeks, advance to onabotulinumtoxinA (Botox) injections for axillary hyperhidrosis. 1, 4, 3

• OnabotulinumtoxinA provides 3-9 months of relief per treatment session for axillary disease 4, 3
• For palmar hyperhidrosis, botulinum toxin is fourth-line therapy (not second-line) due to temporary hand muscle weakness and the need for nerve blocks to control injection pain 1, 4, 2
• Repeat injections are required every 3-6 months to maintain efficacy 1, 2
• This is FDA-approved and highly effective, making it the preferred second-line option for axillary disease 4, 3

Third-Line Treatment: Oral Anticholinergics

For patients who fail topical and injectable therapies, or as first-line for craniofacial hyperhidrosis, use oral anticholinergics. 4, 2, 3

• Glycopyrrolate 1-2 mg once or twice daily is preferred over clonidine 0.1 mg twice daily due to better efficacy and tolerability 2
• Oxybutynin is an alternative oral anticholinergic option 4, 5
• Common side effects include dry mouth, blurred vision, and urinary retention 4
• For craniofacial hyperhidrosis specifically, oral anticholinergics (glycopyrrolate or clonidine) are considered first-line therapy, not topical agents 2

Alternative Treatment: Iontophoresis for Palmoplantar Disease

For palmar and plantar hyperhidrosis, consider iontophoresis as third-line therapy after oral medications. 2, 3, 6

• Requires 3-4 sessions weekly initially, then 1-2 maintenance sessions 4
• Tap water iontophoresis is the method of choice for palmoplantar hyperhidrosis 6
• Adding anticholinergic substances to the water produces more rapid therapeutic success with longer duration 6
• High efficacy but requires significant initial time investment and equipment cost 2

Site-Specific Treatment Algorithm

Axillary Hyperhidrosis:

1. Topical aluminum chloride 10-20% 1, 2, 3
2. Botulinum toxin injections 1, 4, 3
3. Oral anticholinergics (glycopyrrolate preferred) 4, 2
4. Local surgery (curettage, liposuction) 2, 6
5. Endoscopic thoracic sympathectomy (ETS) 2, 3

Palmar/Plantar Hyperhidrosis:

1. Topical aluminum chloride 10-20% 2, 3
2. Oral anticholinergics (glycopyrrolate 1-2 mg once or twice daily) 2
3. Iontophoresis 4, 2, 6
4. Botulinum toxin injections 1, 4, 2
5. ETS for palmar only (not recommended for plantar due to anatomic risks) 2

Craniofacial Hyperhidrosis:

1. Oral anticholinergics (glycopyrrolate or clonidine) 2
2. Topical glycopyrrolate 3
3. Botulinum toxin injections 2, 3
4. ETS for severe cases 2

Critical Pitfalls to Avoid

• Do not confuse primary focal hyperhidrosis with menopausal vasomotor symptoms—menopausal sweating is episodic with sudden waves of heat affecting face/neck/chest, while primary hyperhidrosis is lifelong and affects specific focal areas 4
• Do not use conjugated estrogens or venlafaxine for primary hyperhidrosis, as these treat vasomotor symptoms, not eccrine gland hypersecretion 4
• Before initiating treatment, check thyroid function tests to exclude hyperthyroidism, review medications that may cause sweating, and assess iron stores, vitamin D, and zinc levels 1
• Avoid proceeding to surgical options (local surgery or ETS) until all conservative medical therapies have been exhausted 2, 3, 6