Treatment of Hyperhidrosis (Excessive Sweating)

Step 1 — Treat Underlying Cause (Generalized Hyperhidrosis)

• Systemic diseases: hyperthyroidism, acromegaly, diabetes, pheochromocytoma, lymphoma, carcinoid syndrome, menopause
• Drugs: SSRIs, TCAs, anticholinesterases, opioids, bladder stimulants

Step 2 — Topical Antiperspirants (First-Line for Focal Disease)

• Axillae: 10–35% solution applied nightly to completely dry skin (blow-dry first); wash off after 6–8 hours; occlusion usually not needed
• Palms/soles: Up to 50% concentration, applied nightly alone or occluded with plastic gloves
• Once effective, frequency can be reduced to 1–2×/week for maintenance
• Topical glycopyrrolate also reduces axillary hyperhidrosis

Step 3 — Iontophoresis (Localized Device Therapy)

• Tap water iontophoresis is an effective local alternative, particularly for palmoplantar disease
• 20–30 minute sessions, daily or twice daily until response, then intermittent maintenance (as infrequently as every 2 weeks)
• Adding glycopyrrolate 0.01%, botulinum toxin, or aluminum chloride 2% to the iontophoresis medium may hasten response
• Blocks sweat ducts at the stratum corneum

Step 4 — Botulinum Toxin Injections (Most Effective Before Surgery)

• FDA-approved for axillary hyperhidrosis (onabotulinumtoxinA)
• Frey syndrome remits for 1–10 years in nearly all patients treated
• Repeated injections do not lose efficacy

Step 5 — Systemic (Oral) Medications

• Glycopyrrolate, oxybutynin (also available extended-release), propantheline bromide
• Doses titrated to tolerance; often limited by anticholinergic side effects (dry mouth, urinary retention, blurred vision, constipation)
• Caution: may worsen glaucoma or precipitate convulsions
• Duration of effect ~4–6 hours; many patients use only for special occasions
• Other agents with reported benefit: diltiazem, clonidine

Step 6 — Energy-Based Devices

• Microwave thermolysis (miraDry): selectively heats the dermal-hypodermal junction, thermally destroying eccrine and apocrine glands; high patient satisfaction; side effects include transient edema, erythema, pain, and (longer-term) fibrous bands or muscle weakness
• Radiofrequency via microneedles and laser treatment: appear effective but require further study

Step 7 — Surgical Treatments

• Excision of the most actively sweating skin + undercutting/subcutaneous resection of sweat glands 1–2 cm beyond the excision margin — virtually always effective
• Alternatives: liposuction, surgical ultrasonic aspiration
• Preoperative mapping with starch-iodine or cobalt chloride is critical; active eccrine glands are not always co-located with axillary hair
• Note: botulinum toxin injections were superior to suction-curettage surgery in a comparative trial

• Endoscopic thoracic sympathectomy (ETS) / sympathotomy: produces long-term benefit; however, compensatory hyperhidrosis occurs in up to one-third of patients — a serious concern given the large body surface area affected

Summary Algorithm

Topical aluminum chloride
        ↓ (if fails)
Iontophoresis
        ↓ (if fails)
Botulinum toxin injection
        ↓ (if fails)
Oral anticholinergics / energy devices
        ↓ (if fails)
Surgery (excision/liposuction for axillae; sympathectomy for palms)