Continuing medical education
The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options

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Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.

Section snippets

Trigger avoidance and clothing

Patients should avoid hyperhidrosis (HH) triggers, including crowded areas, emotional provocations, spicy foods, and alcohol.1 The avoidance of tight clothing, man-made synthetic fabrics, and occlusive footwear may also help. Other strategies include masking sweat using underarm liners or dress shields,2, 3, 4 frequent sock and shoe changes, leather shoes, absorbent shoe insoles, foot powder, and cotton or wool socks.5

Topical antiperspirants

Key points

  1. Aluminum chloride hexahydrate is the most commonly used topical medication for mild to moderate hyperhidrosis

  2. Antiperspirants should be applied to dry skin before bedtime

  3. Antiperspirants need to stay on the skin for 6 to 8 hours before being washed off

  4. Aluminum chloride hexahydrate blocks the lumen of the distal eccrine sweat gland ducts

  5. No evidence exists that links the use of aluminum-containing antiperspirants to Alzheimer disease

  6. No clear link exists between the use of aluminum-containing

Oral agents

Key points

  1. Oral systemic medications are reserved for treatment-resistant cases or generalized hyperhidrosis

  2. Anticholinergics are the most commonly used oral medications for hyperhidrosis treatment

  3. Adverse effects of anticholinergic agents force one-third of patients to discontinue treatment

Although not approved by the US Food and Drug Administration (FDA), oral anticholinergics are commonly used for generalized or multifocal primary HH.49, 50 Anticholinergics operate by competitively inhibiting the effect

Iontophoresis

Key points

  1. Iontophoresis is effective and is considered the primary treatment for palmar and plantar hyperhidrosis

  2. At-home iontophoresis treatment devices may yield improved compliance

  3. Alterations to the liquid medium used in iontophoresis devices may amplify the anhidrotic effect

Iontophoresis is a cost-effective, safe therapy approved by the US FDA that is most appropriate for palmar and plantar HH.15, 70 Three devices are registered by the FDA: RA Fischer (RA Fischer Co, Northridge, CA), Hidrex USA

Injectable therapies: BTX

Key points

  1. Botulinum toxin is a common, safe, and effective injectable medication for focal hyperhidrosis

  2. Botulinum toxin injections are administered at the dermal–subcutaneous junction

  3. The most common complaint related to botulinum toxin treatment is pain

  4. Most patients with axillary hyperhidrosis experience excellent results from botulinum toxin treatment

  5. Most patients with hyperhidrosis require 1 to 2 botulinum toxin treatments annually

BTX-A and, to a lesser degree, BTX-B are the serotypes frequently used

Surgical treatment of hyperhidrosis

Key points

  1. Surgery is considered when conservative treatments have failed

  2. Local surgical techniques include excision, curettage, liposuction, or a combination of these techniques

  3. Sympathectomy is the treatment of last resort in the management of hyperhidrosis

  4. The most common long-term complication after sympathectomy is compensatory sweating

Surgery is used when conservative treatments have failed.179 Local surgical techniques for axillary HH include excision, curettage, liposuction, and a combination of

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    Date of release: September 2019

    Expiration date: September 2022

    Funding sources: None.

    Conflicts of interest: None disclosed.

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