Clinical Guidelines
Clinical guidelines for treatment of generalized and focal hyperhidrosis are available, with a treatment algorithm for each type of focal primary hyperhidrosis. These guidelines are offered to help guide professionals in deciding on an optimal therapeutic course for each patient. The set of guidelines for the different anatomic areas affected by hyperhidrosis is offered here based on the hyperhidrosis literature and borrowing heavily from the opinions of investigators writing in multiple publications. Note that there are currently no guidelines for the treatment of hyperhidrosis published by a professional society, such as the American Academy of Dermatology or the American Academy of Neurology.
Generalized Hyperhidrosis
Primary Focal Hyperhidrosis
Generalized Hyperhidrosis
Since generalized hyperhidrosis is usually secondary to an underlying illness, the first approach to providing relief from excessive sweating is to treat the underlying condition (see Causes of Secondary Hyperhidrosis).[6] If symptoms persist during or after treatment of the primary condition, consideration can be given to using a systemic medication to reduce sweating. It will be important to ascertain whether a specific agent is contraindicated in the primary illness and does not interact with drugs used to treat that illness.[19] In the rare instance in which there is no underlying cause found for generalized hyperhidrosis, consideration must be given to treating the most involved areas as one would in focal hyperhidrosis. If symptoms seem to be worse in anxiety-provoking situations, systemic medication can be used.[19]
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Primary Focal Hyperhidrosis
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]
Axillary
Palmar
Plantar
Facial and Gustatory
Axillary
Topical aluminum chloride is the first choice for treatment of axillary hyperhidrosis.[9,58] If symptoms are exacerbated in known anxiety-provoking situations, short-term expectant use of a benzodiazepine or an anticholinergic can be considered.[9,19] Before the availability of botulinum toxin A (BTX-A) injection, more-invasive surgical procedures were the treatment option of last resort (either local excision of axillary sweat glands or ETS).[99] BTX-A injection offers a “minimally invasive treatment option” that should be considered before surgery.[99] Local sweat gland excision by curettage or liposuction, done on an outpatient basis with tumescent local anesthesia, is less invasive than ETS and should be the next step should the patient not respond to BTX-A, need frequent injections to control symptoms, or specifically request the procedure.[7,99] Because of both a response worse than that seen when treating palmar hyperhidrosis and the frequent development of compensatory sweating, ETS is the procedure of last resort for isolated axillary symptoms.[9,99]
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| 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 | |
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Palmar
Topical aluminum chloride is often the first choice for treatment of palmar hyperhidrosis, although a higher concentration (up to 30%) than that used for axillary sweating is usually needed.[145] However, many consider tap water iontophoresis to be the first line of treatment for palmar sweating.[7,145] Iontophoresis is more effective for palmar symptoms than for axillary symptoms and the patient avoids the irritation associated with aluminum chloride use.[7,58] If symptoms are exacerbated in known anxiety-provoking situations, short-term expectant use of a benzodiazepine or an anticholinergic can be considered.[9,19] If symptoms do not resolve with iontophoresis, the two remaining options to consider are BTX-A injection or ETS.[95] Since ETS is more invasive and is associated with high rates of compensatory hyperhidrosis, BTX-A is often recommended first.[95] BTX-A injections in the palm usually require nerve blocks for anesthesia, and some patients experience weakness of intrinsic hand muscles afterward, so the acceptability of this procedure for palmar hyperhidrosis may not be as high as for axillary sweating.[9] For those patients who desire a permanent cessation of sweating or for whom BTX-A injections are not effective or not tolerated, ETS is the procedure of choice.[9,95]
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| 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 | |
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Plantar
Good foot hygiene for patients with plantar hyperhidrosis requires keeping the feet as dry as possible by use of absorbent foot powder, choosing appropriate footwear, and frequent change of shoes and socks.[145,148] Topical aluminum chloride is often the first choice for treatment of plantar hyperhidrosis, although a higher concentration (up to 30%) than that used for axillary sweating is usually needed.[145] However, many consider tap water iontophoresis to be the first line of treatment for plantar sweating.[7,145] Iontophoresis is more effective for plantar symptoms than for axillary symptoms, and the patient avoids the irritation associated with aluminum chloride use.[7,58] If symptoms do not resolve with iontophoresis, the next option to consider is BTX-A injection.[95] Because of the sensitivity of the feet and the large surface area requiring up to 36 injections, plantar sweating is said to be “more tedious and uncomfortable to treat.”[29] If there is no response to botulinum toxin injection, the last therapeutic option to consider is using systemic medication. If symptoms are exacerbated in known anxiety-provoking situations, short-term expectant use of a benzodiazepine or anticholinergic can also be considered. [9,19]
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Facial and Gustatory
Gustatory sweating can be controlled in part by avoiding foods known to stimulate sweating for the individual, commonly coffee, chocolate, spicy or sour foods, hot foods, alcohol, foods or drinks containing citric acid, and/or sweets.[19,83,145] If primary facial hyperhidrosis is worsened by anxiety-provoking situations, short-term expectant use of a benzodiazepine or anticholinergic can be considered.[9,19] Aluminum chloride hexahydrate can be used for facial and gustatory sweating.[58] Most, however, recommend BTX-A injections as a first-line treatment for facial and gustatory sweating.[80,84] Certainly, if aluminum chloride is not effective or is too irritating, the next choice for treatment would be BTX-A therapy.[9,58] The treatment of last resort for facial sweating is ETS, as there is evidence from small series of patients that ETS is effective for this indication, albeit not as effective as for palmar sweating.[6,112]
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