eMedicine Specialties > Dermatology > Diseases of the Adnexa

Hyperhidrosis: Treatment & Medication

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Rachel Altman, MD, Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School; George Kihiczak, MD, Clinical Associate Professor, Department of Dermatology, New Jersey Medical School and University Hospital
Contributor Information and Disclosures

Updated: May 29, 2009

Treatment

Medical Care

Therapy can be challenging for both the patient and the physician. Both topical and systemic medications have been used. Other treatment options include iontophoresis and botulinum toxin injections.

  • Topical agents include topical anticholinergics, boric acid, 2-5% tannic acid solutions, resorcinol, potassium permanganate, formaldehyde (which may cause sensitization14 ), glutaraldehyde, and methenamine. All of these agents are limited by staining, contact sensitization, irritancy, or limited effectiveness. Because of the limitations of other agents, Drysol (20% aluminum chloride hexahydrate in absolute anhydrous ethyl alcohol) is more commonly used as the first-line topical agent. Drysol should be applied nightly on dry skin with or without occlusion until a positive result is obtained, after which the intervals between applications may be lengthened. To minimize irritation, the remainder of the medication should be washed off when the patient awakes, and the area may be neutralized with the topical application of baking soda.15
  • Systemic agents used to treat hyperhidrosis include anticholinergic medications. Anticholinergics such as propantheline bromide, glycopyrrolate, oxybutynin, and benztropine are effective because the preglandular neurotransmitter for sweat secretion is acetylcholine (although the sympathetic nervous system innervates the eccrine sweat glands).16 The use of anticholinergics may be unappealing because their adverse effect profile includes mydriasis, blurry vision, dry mouth and eyes, difficulty with micturition, and constipation. In addition, other systemic medications, such as sedatives and tranquilizers, indomethacin, and calcium channel blockers, may be beneficial in the treatment of palmoplantar hyperhidrosis.
  • Iontophoresis was introduced in 1952 and consists of passing a direct current across the skin.17,18,19 The mechanism of action remains under debate. In palmoplantar hyperhidrosis, the daily treatment of each palm or sole for 30 minutes at 15-20 mA with tap water iontophoresis is effective.20 Intact skin can endure 0.2-mA/cm2 galvanic current without negative consequences, and as much as 20-25 mA per palm may be tolerated.20 Numerous agents have been used to induce hypohidrosis, including tap water and anticholinergics; however, treatment with anticholinergic iontophoresis is more effective than tap water iontophoresis.21
  • Botulinum toxin injections are effective because of their anticholinergic effects at the neuromuscular junction and in the postganglionic sympathetic cholinergic nerves in the sweat glands.22,23,24,25 See Botulinum Toxin for more information.
    • In palmar hyperhidrosis, 50 subepidermal injections of 2 mouse units per palm (total 100 mouse units per palm) results in anhydrosis lasting 4-12 months.26 Each injection produces an area of anhydrosis approximately 1.2 cm in diameter. The only adverse effect is mild transient thumb weakness that resolves within 3 weeks. Adverse effects of intradermal injections of botulinum A toxin may result from diffusion into underlying muscles.27
    • In a similar study, the effects of sodium chloride solution injections in one palm were compared with botulinum toxin injections in the other palm.28 Treatment with 120 mouse units of botulinum toxin (injected into 6 sites in the palm) resulted in a 26% reduction in sweat production after 3 and 8 weeks and a 31% reduction after 13 weeks. Noted adverse effects included minor muscle weakness at the toxin-treated sites, which resolved after 2-5 weeks. Injections of botulinum toxin must be repeated at varying intervals to maintain long-term results.
    • Treatment of axillary hyperhidrosis with botulinum toxin type A reconstituted in lidocaine or in normal saline was described in a randomized, side-by-side, double-blind study.29 The results were the same; however, injections of botulinum toxin A reconstituted in lidocaine are associated with significantly reduced pain, thus, lidocaine-reconstituted botulinum toxin A may be preferable for treating axillary hyperhidrosis.
    • A 2008 study found botulinum toxin type A to be more effective than topical 20% aluminum chloride for the treatment of moderate-to-severe primary focal axillary hyperhidrosis.30
    • Woolery-Lloyd et al reported on successful treatment of inguinal hyperhidrosis with botulinum toxin A. The condition was initially misdiagnosis as urinary incontinence.31
    • The American Academy of Neurology guidelines Assessment: botulinum neurotoxin in the treatment of autonomic disorders and pain (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology may be of interest.32

Surgical Care

In addition to pharmacologic therapy, other treatments include surgical sympathectomy, surgical excision of the affected areas, and subcutaneous liposuction. Each modality has been used effectively.

Palmar hyperhidrosis is a benign functional disorder that is a psychological and social handicap.33 A survey showed thoracoscopic sympathectomy to be minimally invasive and to improve the patient's quality of life, even if compensatory hyperhidrosis occurs.

  • Sympathectomy has been used as a permanent effective treatment since 1920. Usually, it is reserved for the final treatment option.34 Sympathectomy involves the surgical destruction of the ganglia responsible for hyperhidrosis.35,36,37
    • The second (T2) and third (T3) thoracic ganglia are responsible for palmar hyperhidrosis, the fourth (T4) thoracic ganglia controls axillary hyperhidrosis, and the first (T1) thoracic ganglia controls facial hyperhidrosis.
    • Two surgical approaches are available: an open approach and a newer endoscopic approach. The endoscopic approach has become favored because of its improvements in terms of complications, surgical scars, and surgical times. Endoscopic thoracic sympathectomy is an effective treatment for hyperhidrosis; in one study, immediate positive results occurred in 832 (98%) of 850 patients.7 After a 31-month average follow-up, symptoms recurred in 17 patients. Improved quality of life has been described for upper limb hyperhidrosis after treatment with limited endoscopic thoracic sympathetic block at T4.38
    • Numerous complications are associated with this endoscopic treatment option; these include compensatory sweating (induction of sweating in previously unaffected areas of the body), gustatory sweating, pneumothorax, intercostal neuralgia, Horner syndrome, recurrence of hyperhidrosis, and the sequelae of general anesthetic use.
      • Of 850 patients who underwent endoscopic transthoracic sympathectomy, 55% had compensatory sweating (mostly on the trunk), and 36% had gustatory sweating.7 In a similar study39 of 72 patients who underwent transthoracic endoscopic sympathectomy (T2 or T2 and T3) for palmar hyperhidrosis, the success rate was 93%; compensatory sweating occurred in an overwhelming 99% of patients within 1 month after surgery, and gustatory sweating occurred in 17%. The overall occurrence of severe compensatory hyperhidrosis was reduced after T3 ganglionectomy as opposed to ganglionectomies performed at all other levels.40
      • T4 ganglion interruption for palmar hyperhidrosis is an effective approach that can simultaneously minimize the rate of compensatory hyperhidrosis.41 Thus, T4 sympathectomy may be an effective cure. Its rate of compensatory hyperhidrosis appears to be remarkably low compared with T2 sympathetic ganglionic interruption. An effective treatment for such compensatory sweating is the intradermal injection of botulinum toxin.42
      • Li et al reported on minimizing endoscopic thoracic sympathectomy for hyperhidrosis of the palms using the skin temperature of the palms and Doppler-guided blood flow analysis as aids.43
      • Topical glycopyrrolate application may be effective and safe for the treatment of excessive facial sweating in primary craniofacial and secondary gustatory hyperhidrosis following sympathectomy.44
  • Surgical excision of the affected area (identified with iodine starch testing) removes the appropriate sweat glands, thereby eliminating sweating. This technique is particularly useful in axillary hyperhidrosis.
  • The treatment of axillary hyperhidrosis using the 1064-nm Nd-YAG laser was found to be effective and safe in a pilot trial.45
  • Subcutaneous liposuction is another means of removing the eccrine sweat glands responsible for axillary hyperhidrosis. Compared with classic surgical excision, this modality results in less disruption to the overlying skin, resulting in smaller surgical scars and a diminished area of hair loss.46

Consultations

Consult a neurosurgeon if sympathectomy is necessary in severe cases of hyperhidrosis that are refractory to all other treatments.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications. Control of palmar hyperhidrosis with a new dry-type iontophoretic device has been described.47 Dry-type iontophoresis may reduce palmar sweating more conveniently than other conventional methods.

Aldehydes

These agents reduce perspiration by denaturing keratin and thereby occluding the pores of the sweat glands. They have a short-lasting effect. Contact sensitization is increased, especially with formalin. Aldehydes are used to treat the palms and soles; they are not as effective in the axillae.


Glutaraldehyde solution

2% as Cidex. Not as effective but less staining. 20-50% solution can be diluted to 10% (more effective, especially for feet, but still staining occurs).

Adult

Apply to affected areas 3 times per wk for 2 wk, then every wk or prn

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid contact with eyes or mucous membranes; produces a temporary brown discoloration; may cause local irritation; thermal decomposition may release harmful fumes according to MSDS

Aluminum compounds

These agents are antiperspirants that are used in the management of hyperhidrosis.


Aluminum chloride (20% Drysol)

Certin-Dri and Xerac are over-the-counter products at low concentrations. Work best if applied to a dry area and covered with plastic overnight. Should be washed off in the morning. Effect should be noted within 1 mo.

Adult

Apply to affected area qhs for 2-7 consecutive days prn; to prevent irritation, completely dry area prior to application

Pediatric

Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Not for application on irritated, broken, or recently shaved skin

Anticholinergic agents

The use of these agents is usually avoided because they are poorly tolerated at the required doses when given systemically. Acetylcholine is the preglandular neurotransmitter for sweat secretion. These drugs inhibit the binding of acetylcholine to the cholinergic receptor. Clinical effects usually occur within days.


Propantheline (Pro-Banthine)

Blocks action of acetylcholine at postganglionic parasympathetic receptor sites.

Adult

15 mg PO bid/tid 30 min ac initially; gradually titrate to effect

Pediatric

Not established

Concurrent antacids decrease effects; concurrent disopyramide, TCAs, phenothiazides, corticosteroids, atenolol, digoxin, bretylium, or other drugs with anticholinergic activity increase toxicity; may decrease effectiveness of phenothiazides

Documented hypersensitivity to product or related products; ulcerative colitis; narrow-angle glaucoma; obstructive disease of GI tract or urinary tract; intestinal atony of elderly or debilitated patients; myasthenia gravis; toxic megacolon; unstable cardiovascular adjustment in acute hemorrhage

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal, CNS, or hepatic disease; caution in geriatric patients and patients with Down syndrome; may cause urinary retention, arrhythmia, CNS dysfunction, visual changes, xerostomia, constipation, or heat intolerance
Confusion may occur in geriatric patients; diarrhea may be early symptom of incomplete intestinal obstruction (in this instance, treatment with propantheline would be inappropriate and possibly harmful); autonomic neuropathy may occur; caution on concomitant administration of belladonna alkaloids, synthetic/semisynthetic anticholinergic agents, narcotic analgesics, type 1 antiarrhythmics, antihistamines, phenothiazines, TCAs, or other psychoactive drugs; additional adverse effects include congestive heart failure, coronary heart disease, hepatic or renal disease, hiatal hernia associated with reflux esophagitis, hypertension, and hyperthyroidism


Glycopyrrolate (Robinul)

Acts in smooth muscle, CNS, and secretory glands to blocks action of acetylcholine at parasympathetic sites.

Adult

1-2 mg PO bid/tid initially, then titrate to effective dose; not to exceed 8 mg/d
Topical formulation of extemporaneously formulated 0.5-1% cream or roll-on lotion; 0.1% solution applied using iontophoresis

Pediatric

<16 years: Not established
>16 years: Administer as in adults

Levodopa decreases effects; concurrent antacids decrease effects; concurrent disopyramide, TCAs, phenothiazides, corticosteroids, atenolol, digoxin, bretylium, or other drugs with anticholinergic activity increase activity; may decrease effectiveness of phenothiazides; Slow-K enteric toxicity

Documented hypersensitivity to product or related products; ulcerative colitis; narrow-angle glaucoma; obstructive disease of GI tract or urinary tract; intestinal atony of elderly or debilitated patients; myasthenia gravis; toxic megacolon; unstable cardiovascular adjustment in acute hemorrhage

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal, CNS, or hepatic disease; caution in geriatric patients and patients with Down syndrome; may cause urinary retention, arrhythmia, CNS dysfunction, visual changes, xerostomia, constipation, or heat intolerance
Confusion may occur in geriatric patients; diarrhea may be early symptom of incomplete intestinal obstruction (in this instance, treatment with propantheline would be inappropriate and possibly harmful); autonomic neuropathy may occur; caution on concomitant administration of belladonna alkaloids, synthetic/semisynthetic anticholinergic agents, narcotic analgesics, type 1 antiarrhythmics, antihistamines, phenothiazines, TCAs, or other psychoactive drugs; additional adverse effects include congestive heart failure, coronary heart disease, hepatic or renal disease, hiatal hernia associated with reflux esophagitis, hypertension, and hyperthyroidism; contains benzyl alcohol (not for use in patients <1 mo)


Benztropine (Cogentin)

Blocks striatal cholinergic receptors; may help balance cholinergic and dopaminergic activity in striatum.

Adult

1-2 mg/d PO; not to exceed 6 mg/d

Pediatric

Not recommended

Decreases effects of levodopa; concurrent antacids decrease effects; concurrent disopyramide, TCAs, phenothiazides, corticosteroids, atenolol, digoxin, bretylium, or other drugs with anticholinergic activity increase toxicity; may decrease effectiveness of phenothiazides

Documented hypersensitivity to product or related products; children <3 y; ulcerative colitis; narrow-angle glaucoma; obstructive disease of GI tract or urinary tract; intestinal atony of elderly or debilitated patients; myasthenia gravis; toxic megacolon; unstable cardiovascular adjustment in acute hemorrhage

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal, CNS, or hepatic disease; caution in geriatric patients and patients with Down syndrome; may cause urinary retention, arrhythmia, CNS dysfunction, visual changes, xerostomia, constipation, or heat intolerance
Confusion may occur in geriatric patients; diarrhea may be early symptom of incomplete intestinal obstruction (in this instance, treatment with propantheline would be inappropriate and possibly harmful); autonomic neuropathy may occur; caution on concomitant administration of belladonna alkaloids, synthetic/semisynthetic anticholinergic agents, narcotic analgesics, type 1 antiarrhythmics, antihistamines, phenothiazines, TCAs, or other psychoactive drugs; additional adverse effects include congestive heart failure, coronary heart disease, hepatic or renal disease, hiatal hernia associated with reflux esophagitis, hypertension, and hyperthyroidism


Oxybutynin (Ditropan)

Inhibits action of acetylcholine on smooth muscle and has direct antispasmodic effect on smooth muscles.

Adult

Immediate release: 5 mg PO bid/tid; not to exceed 5 mg qid
Extended release: 5 mg or 10 mg PO qd at same time each day; dose may be increased in 5-mg increments qwk, not to exceed 30 mg/d

Pediatric

<5 years: Not established
>5 years: 5 mg (immediate release) PO bid; not to exceed 5 mg tid
>6 years: 5 mg (extended release) PO qd at same time each day; dose may be increased in 5-mg increments, not to exceed 20 mg/d

Effects decrease with concurrent antacids; concurrent disopyramide, TCAs, phenothiazides, corticosteroids, atenolol, digoxin, bretylium, or other drugs with anticholinergic activity increase toxicity; may decrease effectiveness of phenothiazides

Documented hypersensitivity to product or related products; ulcerative colitis; narrow-angle glaucoma; obstructive disease of GI tract or urinary tract; intestinal atony of elderly or debilitated patients; myasthenia gravis; toxic megacolon; unstable cardiovascular adjustment in acute hemorrhage

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal, CNS, or hepatic disease; caution in geriatric patients and patients with Down syndrome; may cause urinary retention, arrhythmia, CNS dysfunction, visual changes, xerostomia, constipation, or heat intolerance
Confusion may occur in geriatric patients; diarrhea may be early symptom of incomplete intestinal obstruction (in this instance, treatment with propantheline would be inappropriate and possibly harmful); autonomic neuropathy may occur; caution on concomitant administration of belladonna alkaloids, synthetic/semisynthetic anticholinergic agents, narcotic analgesics, type 1 antiarrhythmics, antihistamines, phenothiazines, TCAs, or other psychoactive drugs; additional adverse effects include congestive heart failure, coronary heart disease, hepatic or renal disease, hiatal hernia associated with reflux esophagitis, hypertension, and hyperthyroidism

Neuromuscular blocking agents

These agents inhibit the transmission of nerve impulses at the neuromuscular junction of skeletal muscle and/or autonomic ganglia.


Botulinum toxin A (BOTOX®)

Prevents calcium-dependent release of acetylcholine and produces a state of denervation at the neuromuscular junction and postganglionic sympathetic cholinergic nerves in the sweat glands.
Each injection produces an area of anhydrosis approximately 1.2 cm in diameter. Reportedly results in anhydrosis lasting 4-12 mo.
Injections of botulinum toxin must be repeated at varying intervals to maintain long-term results.

Adult

Palmar hyperhidrosis: 50 subepidermal injections of 2 U per palm (total 100 U per palm)
Axillary hyperhidrosis: 50 U/axilla injected intradermally each axilla in 0.1-0.2 mL aliquots to multiple (10 to 15) sites in each axilla

Pediatric

Not established

Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not exceed recommended dosages and frequencies of administration; presence of antibodies to botulinum toxin type A may reduce effects of therapy; mild transient thumb weakness and muscle weakness at toxin-treated sites may occur but resolve within 2-5 wk
Units of biological activity of botulinum toxin type A cannot be compared to nor converted into units of any other botulinum toxin; relative potencies of botulinum A toxin preparations available in United Kingdom and North American differ significantly; reduced blinking as a result of administration of Botox ® Cosmetic may lead to corneal exposure, persistent epithelial defect and corneal ulceration; epinephrine should be available or other precautions taken as necessary should an anaphylactic reaction occur

More on Hyperhidrosis

Overview: Hyperhidrosis
Differential Diagnoses & Workup: Hyperhidrosis
Treatment & Medication: Hyperhidrosis
Follow-up: Hyperhidrosis
References
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Further Reading

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Keywords

hyperhidrosis, excessive sweating, palmoplantar hyperhidrosis, emotionally induced hyperhidrosis, generalized hyperhidrosis, localized hyperhidrosis, palmoplantar sweating, axillary hyperhidrosis, nocturnal hyperhidrosis

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Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Rachel Altman, MD, Staff Physician, Department of Dermatology, UMDNJ-New Jersey Medical School
Rachel Altman, MD is a member of the following medical societies: Alpha Omega Alpha and Sigma Xi
Disclosure: Nothing to disclose.

George Kihiczak, MD, Clinical Associate Professor, Department of Dermatology, New Jersey Medical School and University Hospital
George Kihiczak, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and Medical Society of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Catharine Lisa Kauffman, MD, FACP, Georgetown Dermatology and Georgetown Dermpath
Catharine Lisa Kauffman, MD, FACP is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Royal Society of Medicine, Society for Investigative Dermatology, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Lester F Libow, MD, Dermatopathologist, South Texas Dermatopathology Laboratory
Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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