Primary Focal Plantar

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]

An important first step in the care of the plantar hyperhidrosis patient is to provide education regarding good foot hygiene (to keep the feet as dry as possible). Useful plantar hygienic products include: absorbent foot powder, absorbent insoles for shoes, and moisture-wicking socks. Patients should also be encouraged to wear nonocclusive footwear and to change their shoes and socks frequently.[145,148]

Topical aluminum chloride antiperspirants are often considered the first line of treatment for plantar 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 plantar sweating. [7,145] One of the benefits of iontophoresis for plantar symptoms is that the patient avoids the irritation often associated with aluminum chloride use. Additionally, iontophoresis is often effective for the feet (whereas it is not as effective for the underarms) and, with training, patients can learn to perform the procedure at home.[7, 58]

If symptoms do not resolve with topical antiperspirants or iontophoresis, the next option to consider is botulinum toxin A (BTX-A).[95] When treating plantar hyperhidrosis with BTX-A both physicians and patients should understand that due to the large surface area that usually requires treatment (up to 36 injections may be necessary) and the sensitivity of the feet, the procedure may be "more tedious and uncomfortable" than it would be for palmar or axillary hyperhidrosis. [29]

If the patient does not respond to BTX-A, the last therapeutic option to consider is the use of a systemic medication. Additionally, if symptoms are exacerbated in known anxiety-provoking situations, short-term expectant use of a benzodiazepine or anticholinergic may be considered. [9,19]