Treatment Options for Hyperhidrosis

Abstract

Hyperhidrosis is a disorder of excessive sweating beyond what is expected for thermoregulatory needs and environmental conditions. Primary hyperhidrosis has an estimated prevalence of nearly 3% and is associated with significant medical and psychosocial consequences. Most cases of hyperhidrosis involve areas of high eccrine density, particularly the axillae, palms, and soles, and less often the craniofacial area. Multiple therapies are available for the treatment of hyperhidrosis. Options include topical medications (most commonly aluminum chloride), iontophoresis, botulinum toxin injections, systemic medications (including glycopyrrolate and clonidine), and surgery (most commonly endoscopic thoracic sympathectomy [ETS]). The purpose of this article is to comprehensively review the literature on the subject, with a focus on new and emerging treatment options. Updated therapeutic algorithms are proposed for each commonly affected anatomic site, with practical procedural guidelines. For axillary and palmoplantar hyperhidrosis, topical treatment is recommended as first-line treatment. For axillary hyperhidrosis, botulinum toxin injections are recommended as second-line treatment, oral medications as third-line treatment, local surgery as fourth-line treatment, and ETS as fifth-line treatment. For palmar and plantar hyperhidrosis, we consider a trial of oral medications (glycopyrrolate 1-2 mg once or twice daily preferred to clonidine 0.1 mg twice daily) as second-line therapy due to the low cost, convenience, and emerging literature supporting their excellent safety and reasonable efficacy. Iontophoresis is considered third-line therapy for palmoplantar hyperhidrosis; efficacy is high although so are the initial levels of cost and inconvenience. Botulinum toxin injections are considered fourth-line treatment for palmoplantar hyperhidrosis; efficacy is high though the treatment remains expensive, must be repeated every 3-6 months, and is associated with pain and/or anesthesia-related complications. ETS is a fifth-line option for palmar hyperhidrosis but is not recommended for plantar hyperhidrosis due to anatomic risks. For craniofacial hyperhidrosis, oral medications (either glycopyrrolate or clonidine) are considered first-line therapy. Topical medications or botulinum toxin injections may be useful in some cases and ETS is an option for severe craniofacial hyperhidrosis.

Prevalence and Disease Burden of Hyperhidrosis in the Adult Population

“…For this, a dermatological workup is indicated in all patients seeking help, including clinical and laboratory investigations as well as psychosocial assessment [7]. A variety of treatment options is available and can be applied according to the trigger factors and causes of hyperhidrosis [8,9]. …”

A phase 2a randomized controlled study to evaluate the pharmacokinetic, safety, tolerability and clinical effect of topically applied Umeclidinium in subjects with primary axillary hyperhidrosis

“…11,12 A review of oral anticholinergic therapy for hyperhidrosis indicated that 40% of subjects in clinical studies withdraw from the treatment due to AEs. 9 Consequently, developing topical anticholinergic drugs is an ideal approach to treat hyperhidrosis as sweat glands are surrounded with cholinergic sympathetic nerves.…”

Craniofacial hyperhidrosis can usually be managed pharmacologically, but surgery may sometimes be needed

“…Oral oxybutynin is an important option in managing this condition, especially in patients with multifocal hyperhidrosis [1], and has improved HR-QOL-related measures in uncontrolled studies [5,6] ( Table 1). Oral glycopyrrolate (1-2 mg up to three times daily) is also used in the treatment of craniofacial hyperhidrosis [7]; it has shown some promising results in retrospective studies in patients with hyperhidrosis affecting a variety of body sites (response rate of &67 [8] and 79 % [9]), but studies in patients with craniofacial hyperhidrosis are lacking. Topical glycopyrrolate reduced sweat production in a small study [10] ( Table 1); further studies are needed to determine its optimal application regimen and long-term effectiveness [1].…”

“…Fig. 1 Management of primary focal craniofacial hyperhidrosis, as suggested by Nicholas et al [1] Evidence lacking for other options Other pharmacological agents, including topical 20 % aluminium chloride hexahydrate solution, oral clonidine and oral propranolol, have been be used to treat craniofacial hyperhidrosis in clinical practice [1,7]; however, the systematic review by Nicolas et al did not identify any experimental or observational studies supporting their use in this specific indication [1].…”