Approach

The most important issue in directing therapy for hyperhidrosis is to differentiate between types (i.e., primary or secondary), and between subtypes of primary hyperhidrosis (i.e., palmar, plantar, axillary, or craniofacial). A treatment strategy that works well for one form of hyperhidrosis may be unsuccessful for another form. There are several ways to treat hyperhidrosis, including topical and systemic medications, as well as iontophoresis, onabotulinumtoxinA (botulinum toxin type A) injections, local microwave treatment, targeted alkali thermolysis, and surgery. The general recommendation is to use medical therapy before resorting to invasive treatment.

The impact of hyperhidrosis on the patient’s quality of life should be established in order to tailor the management plan. The effect of hyperhidrosis on daily activities, relationships, and psychologic well-being, should all be taken into account when deciding on the most appropriate treatment options.

Axillary hyperhidrosis

Topical aluminum chloride is the first-line treatment for axillary hyperhidrosis and is usually effective.[2][11][19] Commonly used preparations include 20% aluminum chloride in ethanol and 6.25% aluminum tetrachloride. Local stinging and burning may occur due to formation of hydrochloric acid when sweat combines with the aluminum chloride. Topical baking soda or hydrocortisone cream may help if this occurs.[11]

If symptoms do not resolve with aluminum chloride, onabotulinumtoxinA injections may be considered. OnabotulinumtoxinA is approved in the US for axillary use and can be effective for months at a time.[11][20] The agent inhibits the release of acetylcholine at the sympathetic cholinergic nerve terminals that innervate eccrine sweat glands. The injection process may be painful. However, local topical anesthetic may help.[11]

If the patient does not respond to onabotulinumtoxinA or does not want repeated painful shots with temporary results, a targeted alkali thermolysis (TAT) technology patch is another treatment option. It has been approved by the Food and Drug Administration (FDA) for the treatment of primary axillary hyperhidrosis. In TAT, the sodium in the path interacting with the water of the sweat produces thermal energy causing local inactivation of the sweat glands for a period of several months. A double-blinded multicenter study showed a statistically significant improvement compared to placebo, with a decrease in sweat production by more than half in 60% of those treated.[21]

Local microwave treatment is another noninvasive treatment option for primary axillary hyperhidrosis.[16][22][23] It works by destroying eccrine sweat glands through thermolysis. In one study, 90% of patients who received microwave therapy experienced a 50% reduction in axillary sweat at 12 months follow-up.[24]

Local sweat gland excision by curettage or liposuction should be considered if the less invasive treatments fail. Local axillary gland surgeries (including subcutaneous gland resection with or without resection of the overlying skin, curettage-liposuction, or electrosurgical or laser glandular destruction) have been shown to be effective.[25][26][27][28][29]​ Local procedures seem to be more effective with better patient satisfaction than thoracoscopic sympathetic surgeries, and have less compensatory and gustatory sweating.[30] Axillary surgery may result in poor wound healing or scarring. Unlike surgical sympathectomy, local surgical procedures generally have no systemic manifestations (e.g., compensatory hyperhidrosis).

If symptoms persist, endoscopic thoracoscopic sympathectomy (ETS) may be considered.[31]​ This is a minimally invasive video-assisted procedure.[10] The specific hyperhidrosis disorder determines the level of the sympathetic procedure. For example, surgery at the third (T3) or fourth (T4) thoracic ganglia is recommended for axillary hyperhidrosis. Some controversy exists whether compensatory sweating is more problematic at higher sympathectomy levels, but patient selection is likely far more important.[32] Sympathetic surgery at T3 or T4 can be expected to benefit 80% to 90% of patients with axillary hyperhidrosis. However, several studies have shown that sympathetic surgery in patients with axillary hyperhidrosis is less successful and that the level of patient satisfaction is lower than it is for patients with palmar hyperhidrosis.[14][33][34][35][36][37][38][39][40]

For those patients with symptoms exacerbated in known anxiety-provoking situations, a short-term oral anticholinergic (e.g., glycopyrrolate, oxybutynin) taken as required can be considered together with any of the other therapies, although its side effects (e.g., dry eyes and mouth, urinary retention, cramps, weakness, nausea, and headache) may limit its usefulness.[16]​ Glycopyrrolate (as glycopyrronium) is also available as a topical wipe and is approved for patients with primary axillary hyperhidrosis. [Figure caption and citation for the preceding image starts]: Thoracoscopic view of the left upper posterior mediastinum with the sympathetic chain visualized over the 2nd, 3rd, and 4th costal heads (R2, R3, and R4, respectively)From the personal collection of Fritz Baumgartner, MD [Citation ends].com.bmj.content.model.Caption@4af6402d

Palmar hyperhidrosis

Topical aluminum chloride is often the first-choice treatment for palmar hyperhidrosis but tends to be less effective than it is for treating axillary hyperhidrosis.[2][11][19][31]​​[41]​​

For patients who do not respond or cannot tolerate topical aluminum chloride on their hands, iontophoresis with tap water may be used. Using an iontophoresis device, ions are introduced into cutaneous tissues via an electrical current. The mechanism most likely involves the ionic current temporarily blocking the sweat duct at the level of the stratum corneum. The addition of anticholinergics or onabotulinumtoxinA to the iontophoresis tap water may improve its efficacy.[11][42] Skin irritation from galvanic currents may occur. Iontophoresis is contraindicated in patients with pacemakers or metal implants, or who are pregnant.[11]

ETS is appropriate for severe, debilitating localized palmar sweating when other treatments have failed. The procedure is generally done on both sides at the same sitting, under general anesthesia. ETS can usually be performed in a short-stay setting. In cases of disabling palmar hyperhidrosis, the expected benefits generally outweigh the known side effects, which may include compensatory sweating.[9][14] Sympathetic surgery at the second (T2) or third (T3) thoracic ganglia yields curative results for palmar sweating in >95% of cases.

For patients with severe palmar and severe plantar hyperhidrosis (palmoplantar hyperhidrosis), ETS is recommended.[9][14][15][35][39][41][43][44][45][46][47][48][49] Surgery can be performed at the T2 or T3 level, although some suggest the T4 level. The best level to select is unclear and controversial. Surgery at the T2 level may be more consistently curative with less dramatic failures than at T3,​​ but is associated with an increased incidence of compensatory hyperhidrosis postoperatively.[48][49][50]​​[51] However, excellent long-term results with a low (1.3%) rate of severe compensatory sweating have been reported by some using the T2 level.[52] Successful outcomes for palmar sweating are achieved in >95% of cases.[51] Plantar sweating is improved in the short term in approximately 80% of cases, although not as dramatically as the palmar sweating, and it becomes less effective with time.

Because of the higher incidence of moderate or severe compensatory hyperhidrosis, some recommend avoiding T2 procedures altogether, although others report excellent results using the T2 level.[49][52]​ Some even recommend levels of sympathetic intervention for palmoplantar hyperhidrosis at levels lower than T3 (i.e., over the 4th or 5th rib levels), although this may result in "moister hands."[48] It is suggested that proper patient selection is far more important than sympathectomy level in achieving patient satisfaction regarding compensatory sweating.[15]

Some surgeons perform ramicotomy rather than sympathetic nerve/ganglion intervention to limit the severity of compensatory sweating. However, the incidence of recurrent sweating does seem to be higher with ramicotomy.[53] Thoracoscopic sympathetic intervention can be safe and effective in younger patients, even in early teenage years, and has been shown to result in markedly improved long-term quality of life compared to nonoperative cohorts.[54]

For those patients with symptoms exacerbated in known anxiety-provoking situations, a short-term oral anticholinergic (e.g., glycopyrrolate, oxybutynin) taken as required can be considered together with any of the other therapies, although its side effects (e.g., dry eyes and mouth, urinary retention, cramps, weakness, nausea, and headache) may limit its usefulness. Glycopyrrolate (as glycopyrronium) is also available as a topical wipe.[Figure caption and citation for the preceding image starts]: Thoracoscopic view of the right upper posterior mediastinum with the sympathetic chain visualized over the 2nd and 3rd rib costal heads (R2 and R3, respectively). Transection of the sympathetic chain at the level of T2 on the right and left sides is curative for palmar hyperhidrosisFrom the personal collection of Fritz Baumgartner, MD [Citation ends].com.bmj.content.model.Caption@4d3226e1

Plantar hyperhidrosis

Management of localized plantar sweating is primarily medical.

Initial management includes keeping the feet as dry as possible by use of absorbent foot powders and shoe inserts, with frequent changing of socks and shoes.

If these measures are ineffective, then topical aluminum chloride, or, as a next choice, iontophoresis may be used. Topical aluminum chloride tends not to be as effective as in localized axillary hyperhidrosis.[41]

Lumbar sympathectomy procedures are not encouraged or routine due to autonomic side effects.

For those patients with symptoms exacerbated in known anxiety-provoking situations, a short-term oral anticholinergic (e.g., glycopyrrolate, oxybutynin) taken as required can be considered together with any of the other therapies, although its side effects (e.g., dry eyes and mouth, urinary retention, cramps, weakness, nausea, and headache) may limit its usefulness. Glycopyrrolate (as glycopyrronium) is also available as a topical wipe.

Craniofacial hyperhidrosis

Topical aluminum chloride can be used for facial sweating.[11]

ETS is useful for localized craniofacial hyperhidrosis, although there is a higher incidence of patient dissatisfaction and complaints of compensatory sweating compared with palmar hyperhidrosis.[14][33][34][35][36]​​[37]​​[38][39][40] Most patients with disabling craniofacial hyperhidrosis will have significant benefit from sympathetic surgery at the T2 level. Nonetheless, treatment of craniofacial hyperhidrosis should be considered very carefully because side effects can be severe.

For those patients with symptoms exacerbated in known anxiety-provoking situations, a short-term oral anticholinergic (e.g., glycopyrrolate, oxybutynin) taken as required can be considered together with any of the other therapies, although the side effects (e.g., dry eyes and mouth, urinary retention, cramps, weakness, nausea, and headache) may limit its usefulness. Glycopyrrolate (as glycopyrronium) is also available as a topical wipe.

Secondary hyperhidrosis

This form of hyperhidrosis is a manifestation of an underlying pathology, and necessitates treating the primary cause of the disorder. For example, focal sweating may result from acute spinal cord injury, cerebral or medullary infarcts, or other nerve injuries (e.g., posttraumatic vasomotor dystrophy), and facial gustatory sweating may be caused by Frey syndrome. More generalized sweating may be due to endocrine, neoplastic, infectious, drug, and toxicologic-related problems and, depending on the history and physical examination, may require additional testing. If symptoms persist after treatment of the underlying condition, oral anticholinergic medication (e.g., glycopyrrolate, oxybutynin) to reduce sweating may be appropriate, although the side effects (e.g., dry eyes and mouth, urinary retention, cramps, weakness, nausea, and headache) may limit its usefulness. Glycopyrrolate (as glycopyrronium) is also available as a topical wipe.

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