Hyperhidrosis: Management Options

 

Am Fam Physician. 2018 Jun 1;97(11):729-734.

  Patient information: See related handout on excessive sweating (hyperhidrosis), written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Hyperhidrosis is excessive sweating that affects patients' quality of life, resulting in social and work impairment and emotional distress. Primary hyperhidrosis is bilaterally symmetric, focal, excessive sweating of the axillae, palms, soles, or craniofacial region not caused by other underlying conditions. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication use. The Hyperhidrosis Disease Severity Scale is a validated survey used to grade the tolerability of sweating and its impact on quality of life. The score can be used to guide treatment. Topical aluminum chloride solution is the initial treatment in most cases of primary focal hyperhidrosis. Topical glycopyrrolate is first-line treatment for craniofacial sweating. Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line treatment for axillary, palmar, plantar, or craniofacial hyperhidrosis. Iontophoresis should be considered for treating hyperhidrosis of the palms and soles. Oral anticholinergics are useful adjuncts in severe cases of hyperhidrosis when other treatments fail. Local microwave therapy is a newer treatment option for axillary hyperhidrosis. Local surgery and endoscopic thoracic sympathectomy should be considered in severe cases of hyperhidrosis that have not responded to topical or medical therapies.

Hyperhidrosis is excessive sweating beyond what is physiologically required for thermoregulation, often causing social, emotional, and work impairment. This condition can be primary or secondary. Primary hyperhidrosis is idiopathic, bilaterally symmetric, excessive sweating of the axillae, palms, soles, face, and, less commonly, scalp or inguinal folds. Secondary hyperhidrosis may be focal or generalized, and is caused by an underlying medical condition or medication use.1,2

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The Hyperhidrosis Disease Severity Scale should be used to gauge severity of primary hyperhidrosis and predict response to treatment.

C

2, 4, 6, 7

Topical 20% aluminum chloride (Drysol) should be used as first-line treatment in most cases of primary hyperhidrosis, regardless of severity and location.

C

2, 4

Iontophoresis may be effective as first- or second-line treatment for primary hyperhidrosis of the palms or soles.

C

2, 4

Intradermal onabotulinumtoxinA (Botox) injections may be considered first- or second-line treatments for many cases of primary hyperhidrosis involving the axillae, palms, soles, or face.

C

2, 4

Oral anticholinergics are recommended if treatment with topical aluminum chloride, onabotulinumtoxinA injection, and iontophoresis is ineffective.

C

4

Local surgery and endoscopic thoracic sympathectomy should be considered only after topical and medical treatments have failed.

C

2, 4, 9, 26, 29


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The Hyperhidrosis Disease Severity Scale should be used to gauge severity of primary hyperhidrosis and predict response to treatment.

C

2, 4, 6, 7

Topical 20% aluminum chloride (Drysol) should be used as first-line treatment in most cases of primary hyperhidrosis, regardless of severity and location.

C

2, 4

Iontophoresis may be effective as first- or second-line treatment for primary hyperhidrosis of the palms or soles.

C

2, 4

Intradermal onabotulinumtoxinA (Botox) injections may be considered first- or second-line treatments for many cases of primary hyperhidrosis involving the axillae, palms, soles, or face.

C

2, 4

Oral anticholinergics are recommended if treatment with topical aluminum chloride, onabotulinumtoxinA injection, and iontophoresis is ineffective.

C

4

Local surgery and endoscopic thoracic sympathectomy should be considered only after topical and medical treatments have failed.

C

2, 4, 9, 26, 29


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology

Hyperhidrosis affects 1% to 3% of the U.S. population, yet less than one-half of those affected discuss this with their physician.3 More than 90% of hyperhidrosis cases are primary, and more than one-half of these cases affect the axillae.2,3 More than one-third of persons with axillary

The Authors

show all author info

JOHN R. McCONAGHY, MD, is vice chair of the Department of Family Medicine and associate director of the Family Medicine Residency Program at The Ohio State University Wexner Medical Center, Columbus....

DANIEL FOSSELMAN, DO, is a third-year resident in the Department of Family Medicine at The Ohio State University Wexner Medical Center.

Author disclosure: No relevant financial affiliations.

Address correspondence to John R. McConaghy, MD, The Ohio State University Medical Center, 2231 N. High St., Columbus, OH 43201 (e-mail: john.mcconaghy@osumc.edu). Reprints are not available from the authors.

References

show all references

1. Walling HW. Clinical differentiation of primary from secondary hyperhidrosis. J Am Acad Dermatol. 2011;64(4):690–695....

2. Hornberger J, Grimes K, Naumann M, et al.; Multi-Specialty Working Group on the Recognition, Diagnosis, and Treatment of Primary Focal Hyperhidrosis. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004;51(2):274–286.

3. Strutton DR, Kowalski JW, Glaser DA, Stang PE. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol. 2004;51(2):241–248.

4. Solish N, Bertucci V, Dansereau A, et al. A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg. 2007;33(8):908–923.

5. Smith CC, Pariser D. Primary focal hyperhidrosis. Up-To-Date. https://www.uptodate.com/contents/primary-focal-hyperhidrosis [login required]. Accessed September 20, 2017.

6. Hamm H, Naumann MK, Kowalski JW, Kütt S, Kozma C, Teale C. Primary focal hyperhidrosis: disease characteristics and functional impairment. Dermatology. 2006;212(4):343–353.

7. Hamm H. Impact of hyperhidrosis on quality of life and its assessment. Dermatol Clin. 2014;32(4):467–476.

8. Nicholas R, Quddus A, Baker DM. Treatment of primary craniofacial hyperhidrosis: a systematic review. Am J Clin Dermatol. 2015;16(5):361–370.

9. Saenz JW, Sams RW II, Jamieson B. FPIN's clinical inquiries. Treatment of hyperhidrosis. Am Fam Physician. 2011;83(4):465–466.

10. Hoorens I, Ongenae K. Primary focal hyperhidrosis: current treatment options and a step-by-step approach. J Eur Acad Dermatol Venereol. 2012;26(1):1–8.

11. Eisenach JH, Atkinson JL, Fealey RD. Hyperhidrosis: evolving therapies for a well-established phenomenon [published correction appears in Mayo Clin Proc. 2005;80(6): 828]. Mayo Clin Proc. 2005;80(5):657–666.

12. Togel B, Greve B, Raulin C. Current therapeutic strategies for hyperhidrosis: a review. Eur J Dermatol. 2002;12(3):219–223.

13. Hölzle E. Topical pharmacological treatment. Curr Probl Dermatol. 2002;30:30–43.

14. Swaile DF, Elstun LT, Benzing KW. Clinical studies of sweat rate reduction by an over-the-counter soft-solid antiperspirant and comparison with a prescription anti-perspirant product in male panelists. Br J Dermatol. 2012;166(suppl 1):22–26.

15. Stolman LP. Treatment of hyperhidrosis. Dermatol Clin. 1998;16(4):863–869.

16. Pariser DM, Ballard A. Iontophoresis for palmar and plantar hyperhidrosis. Dermatol Clin. 2014;32(4):491–494.

17. de Almeida AR, Montagner S. Botulinum toxin for axillary hyperhidrosis. Dermatol Clin. 2014;32(4):495–504.

18. Glogau RG. Hyperhidrosis and botulinum toxin A: patient selection and techniques. Clin Dermatol. 2004;22(1):45–52.

19. Lowe NJ, Glaser DA, Eadie N, Daggett S, Kowalski JW, Lai PY; North American Botox in Primary Axillary Hyperhidrosis Clinical Study Group. Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. J Am Acad Dermatol. 2007;56(4):604–611.

20. Weinberg T, Solish N, Murray C. Botulinum neurotoxin treatment of palmar and plantar hyperhidrosis. Dermatol Clin. 2014;32(4):505–515.

21. Cruddas L, Baker DM. Treatment of primary hyperhidrosis with oral anticholinergic medications: a systematic review. J Eur Acad Dermatol Venereol. 2017;31(6):952–963.

22. Jacob C. Treatment of hyperhidrosis with microwave technology. Semin Cutan Med Surg. 2013;32(1):2–8.

23. Hong HC, Lupin M, O'Shaughnessy KF. Clinical evaluation of a microwave device for treating axillary hyperhidrosis. Dermatol Surg. 2012;38(5):728–735.

24. Fatemi Naeini F, Abtahi-Naeini B, Pourazizi M, Nilforoushzadeh MA, Mirmohammadkhani M. Fractionated microneedle radiofrequency for treatment of primary axillary hyperhidrosis: a sham control study. Australas J Dermatol. 2015;56(4):279–284.

25. Abtahi-Naeini B, Naeini FF, Saffaei A, et al. Treatment of primary axillary hyperhidrosis by fractional microneedle radiofrequency: is it still effective after long-term follow-up? Indian J Dermatol. 2016;61(2):234.

26. Glaser DA, Galperin TA. Local procedural approaches for axillary hyperhidrosis. Dermatol Clin. 2014;32(4):533–540.

27. Lawrence CM, Lonsdale Eccles AA. Selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis: a retrospective clinical and histological review of 15 patients. Br J Dermatol. 2006;155(1):115–118.

28. Cerfolio RJ, De Campos JR, Bryant AS, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg. 2011;91(5):1642–1648.

29. de Andrade Filho LO, Kuzniec S, Wolosker N, Yazbek G, Kauffman P, Milanez de Campos JR. Technical difficulties and complications of sympathectomy in the treatment of hyperhidrosis: an analysis of 1731 cases. Ann Vasc Surg. 2013;27(4):447–453.

30. Thomas I, Brown J, Vafaie J, Schwartz RA. Palmoplantar hyperhidrosis: a therapeutic challenge. Am Fam Physician. 2004;69(5):1117–1121.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Related Content


MOST RECENT ISSUE


Oct 15, 2018

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article