How do you treat hyperhidrosis?

Treatment of Hyperhidrosis

For primary hyperhidrosis, treatment should be selected based on anatomic location and severity, starting with topical aluminum chloride 10-20% for axillary, palmar, and plantar disease, oral glycopyrrolate 1-2 mg once or twice daily for craniofacial disease, and escalating to botulinum toxin injections or other modalities based on response. 1, 2

Initial Evaluation

Before initiating treatment, distinguish primary from secondary hyperhidrosis:

• Primary hyperhidrosis affects axillae, palms, soles, or craniofacial regions bilaterally and symmetrically 1, 3
• Nocturnal sweating strongly suggests secondary causes requiring evaluation for sleep disorders, cardiovascular disease, endocrine disorders, or neurological conditions 1
• Review all medications as many drugs cause secondary hyperhidrosis 1
• Check vital signs including orthostatic blood pressure 1
• Assess for thyroid dysfunction symptoms, sleep disturbances, orthostatic symptoms, and polyuria 1
• Examine sweating distribution, thyroid abnormalities, peripheral edema, and scalp for scaling or inflammation if craniofacial involvement present 1

Laboratory Testing for Suspected Secondary Hyperhidrosis

Order complete blood count, comprehensive metabolic panel, thyroid function tests, hemoglobin A1c, iron studies, vitamin D, zinc levels, and serum calcium 1, 2. Additional testing based on clinical suspicion may include overnight oximetry or polysomnography for sleep disorders, ECG and BNP for cardiovascular concerns, and morning urine osmolality and PTH for endocrine evaluation 1.

Treatment Algorithm by Anatomic Location

Axillary Hyperhidrosis

First-line: Topical aluminum chloride 10-20% solution 4, 3, 5

Second-line: OnabotulinumtoxinA (Botox) injections, which is FDA-approved for severe axillary hyperhidrosis 1, 4. This provides 3-6 months of relief but requires repeated treatments 4, 3.

Third-line: Oral glycopyrrolate 1-2 mg once or twice daily 1, 3

Fourth-line: Local surgery (excision, curettage, liposuction, or combination) 3, 6

Fifth-line: Endoscopic thoracic sympathectomy (ETS) only after failure of all other options 3, 5

Palmar and Plantar Hyperhidrosis

First-line: Topical aluminum chloride 10-20% 3, 5

Second-line: Oral glycopyrrolate 1-2 mg once or twice daily (preferred over clonidine 0.1 mg twice daily) due to low cost, convenience, and emerging literature supporting excellent safety and reasonable efficacy 3

Third-line: Iontophoresis, which has high efficacy though initial cost and inconvenience are significant 3, 5, 7

Fourth-line: Botulinum toxin A injections (high efficacy but expensive, must be repeated every 3-6 months, and associated with pain and/or anesthesia-related complications) 3, 5

Fifth-line: ETS for palmar hyperhidrosis only (not recommended for plantar due to anatomic risks) 3, 5

Craniofacial Hyperhidrosis

First-line: Oral glycopyrrolate 1-2 mg once or twice daily OR topical glycopyrrolate 1, 2, 3

Second-line: Botulinum toxin A injections, requiring careful technique to avoid facial weakness 1, 3

Topical aluminum chloride 10-20% may be used but commonly causes irritation or scaling on the scalp 1, 2.

Critical Considerations and Pitfalls

Anticholinergic Side Effects

Oral glycopyrrolate causes dry mouth, blurred vision, urinary retention, and constipation 1, 2. Elderly patients require close monitoring for cognitive effects and fall risk 1.

Scalp-Specific Issues

• Check vitamin D levels in patients with thick scaling on the scalp 1, 2
• Use high-potency topical steroids if inflammation develops on the scalp 1, 2
• Maintain regular scalp hygiene to prevent secondary complications 2

Common Diagnostic Errors

• Failing to distinguish primary from secondary hyperhidrosis leads to inappropriate treatment 1
• Overlooking medications as causes of secondary hyperhidrosis 1
• Ignoring serious underlying conditions like malignancy in unexplained night sweats 1
• Remember: nocturnal hyperhidrosis is almost always secondary hyperhidrosis requiring evaluation for underlying causes 1

Botulinum Toxin Injection Technique

OnabotulinumtoxinA should be injected into the dermal-subcutaneous junction 6. For craniofacial hyperhidrosis, careful technique is essential to avoid temporary weakness in adjacent muscles depending on injection site 1, 2, 4.

Lifestyle Modifications

Avoid known triggers such as spicy foods, caffeine, and alcohol; wear moisture-wicking materials and appropriate headwear 2.

Monitoring and Follow-up

Monitor for medication side effects, particularly with anticholinergics, and schedule regular follow-up every 3-6 months to adjust treatment as needed 2.