Primary Focal Palmar

The general recommendation is to try more-conservative therapy before resorting to invasive treatment. Each of the anatomic areas with excessive sweating is more or less susceptible to the various approaches available.[9]

Topical aluminum chloride antiperspirants are often considered the first line of treatment for palmar hyperhidrosis, keeping in mind that a higher concentration of active ingredients (up to 30%) than is used to treat axillary hyperhidrosis is often required.[145] Many experts, however, also consider tap water iontophoresis to be a first line treatment for palmar sweating. [7,145] One of the benefits of iontophoresis for palmar symptoms is that the patient avoids the irritation often associated with aluminum chloride use. Additionally, iontophoresis is often effective for the palms (whereas it is not as effective for the underarms) and, with training, patients can learn to perform the procedure at home. [7,58]

As with axillary hyperhidrosis, first line treatment may be different if the patient’s excessive sweating symptoms occur during, or are exacerbated by, known anxiety-provoking situations such as during presentations at work, dramatic performances, etc. In these cases the patient may be treated prior to such events with an anticholinergic or a short course benzodiazepine. [9,19]

If symptoms do not resolve with topical antiperspirants, iontophoresis, or short course oral medications (if appropriate), the remaining options to consider are: botulinum toxin type A (BTX-A) injections, on-going use of systemic medications, or endoscopic thoracic sympathectomy (ETS).[95] Since systemic medications are often associated with side effects precluding long-term treatment and ETS is invasive and associated with high rates of compensatory hyperhidrosis, BTX-A is often recommended first and repeated as necessary to control symptoms.[95]

Starch iodine test, with the darkened area showing location of excessive sweating before and after treatment with BTX-A. Photo courtesy of Markus Naumann, MD