Hyperhidrosis Treatment & Management

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 4, 2011
 

Medical Care

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

Topical agents for hyperhidrosis therapy include topical anticholinergics, boric acid, 2-5% tannic acid solutions, resorcinol, potassium permanganate, formaldehyde (which may cause sensitization[18] ), 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.[19] Axillary hyperhidrosis may be treated with aluminium chloride gel, although the gel may cause mild cutaneous irritation.[20]

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).[21, 22] 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.[23, 24, 25] 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.[26] 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.[26] 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.[27]

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.[28, 29, 30, 31]

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.[32] 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.[33]

In a similar study, the effects of sodium chloride solution injections in one palm were compared with botulinum toxin injections in the other palm.[34] 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.[35] 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.[36]

Woolery-Lloyd et al reported on successful treatment of inguinal hyperhidrosis with botulinum toxin A. The condition was initially misdiagnosis as urinary incontinence.[37]

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.[38]

Bromhidrosis may be treated with a glycine-soja sterocomplex topical agent, which has shown encouraging results on both the intensity and quality of odor in patients with bromhidrosis.[39]

Next

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.[40] 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.[41] Sympathectomy involves the surgical destruction of the ganglia responsible for hyperhidrosis.[42, 43, 44]

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.[8] 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.[45]

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.[8] In a similar study[46] 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.[47]

T4 ganglion interruption for palmar hyperhidrosis is an effective approach that can simultaneously minimize the rate of compensatory hyperhidrosis.[48] 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.[49]

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.[50]

Topical glycopyrrolate application may be effective and safe for the treatment of excessive facial sweating in primary craniofacial and secondary gustatory hyperhidrosis following sympathectomy.[51]

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.[52]

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.[53]

Previous
Next

Consultations

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

Previous
Proceed to Medication
 
 
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, University of Medicine and Dentistry of New Jersey-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.

Specialty Editor Board

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.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M 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, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Altman RS, Schwartz RA. Emotionally induced hyperhidrosis. Cutis. May 2002;69(5):336-8. [Medline].

  2. Ruchinskas R. Hyperhidrosis and anxiety: chicken or egg?. Dermatology. 2007;214(3):195-6. [Medline].

  3. Esen AM, Barutcu I, Karaca S, et al. Peripheral vascular endothelial function in essential hyperhidrosis. Circ J. Jun 2005;69(6):707-10. [Medline].

  4. Yamashita N, Tamada Y, Kawada M, Mizutani K, Watanabe D, Matsumoto Y. Analysis of family history of palmoplantar hyperhidrosis in Japan. J Dermatol. Dec 2009;36(12):628-31. [Medline].

  5. Adar R, Kurchin A, Zweig A, Mozes M. Palmar hyperhidrosis and its surgical treatment: a report of 100 cases. Ann Surg. Jul 1977;186(1):34-41. [Medline].

  6. Cloward RB. Hyperhydrosis. J Neurosurg. May 1969;30(5):545-51. [Medline].

  7. Cloward RB. Treatment of hyperhidrosis palmaris (sweaty hands); a familial disease in Japanese. Hawaii Med J. Mar-Apr 1957;16(4):381-7. [Medline].

  8. Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol. Jul 1995;33(1):78-81. [Medline].

  9. Saglam M, Esen AM, Barutcu I, et al. Impaired left ventricular filling in patients with essential hyperhidrosis: an echo-Doppler study. Tohoku J Exp Med. Apr 2006;208(4):283-90. [Medline].

  10. Tugnoli V, Eleopra R, De Grandis D. Hyperhidrosis and sympathetic skin response in chronic alcoholic patients. Clin Auton Res. Feb 1999;9(1):17-22. [Medline].

  11. Moon SY, Shin DI, Park SH, Kim JS. Harlequin syndrome with crossed sympathetic deficit of the face and arm. J Korean Med Sci. Apr 2005;20(2):329-30. [Medline].

  12. Karaca S, Emul M, Kulac M, et al. Temperament and character profile in patients with essential hyperhidrosis. Dermatology. 2007;214(3):240-5. [Medline].

  13. Walling HW. Clinical differentiation of primary from secondary hyperhidrosis. J Am Acad Dermatol. Feb 17 2011;[Medline].

  14. Rodrigues Masruha M, Lin J, Arita JH, DE Castro Neto EF, Scerni DA, Cavalheiro EA, et al. Spontaneous periodic hypothermia and hyperhidrosis: a possibly novel cerebral neurotransmitter disorder. Dev Med Child Neurol. Dec 17 2010;[Medline].

  15. Martín AF, Figueroa SC, Merino Mde L, Hurlee AD. Hyperhidrosis in association with efavirenz. AIDS Patient Care STDS. Mar 2009;23(3):143-5. [Medline].

  16. Kocyigit P, Akay BN, Saral S, Akbostanci C, Bostanci S. Unilateral hyperhidrosis with accompanying contralateral anhidrosis. Clin Exp Dermatol. Dec 2009;34(8):e544-6. [Medline].

  17. López V, Pinazo I, Santonja N, Jordá E. Eccrine angiomatous hamartoma in a child. Pediatr Dermatol. Sep-Oct 2010;27(5):548-9. [Medline].

  18. Shelley WB, Laskas JJ, Satanove A. Effect of topical agents on planter sweating. AMA Arch Derm Syphilol. Jun 1954;69(6):713-6. [Medline].

  19. Sato K, Kang WH, Saga K, Sato KT. Biology of sweat glands and their disorders. II. Disorders of sweat gland function. J Am Acad Dermatol. May 1989;20(5 Pt 1):713-26. [Medline].

  20. Streker M, Reuther T, Verst S, Kerscher M. [Axillary hyperhidrosis--efficacy and tolerability of an aluminium chloride antiperspirant. Prospective evaluation on 20 patients with idiopathic axillary hyperhidrosis]. Hautarzt. Feb 2010;61(2):139-44. [Medline].

  21. Klaber M, Catterall M. Treating hyperhidrosis. Anticholinergic drugs were not mentioned. BMJ. Sep 16 2000;321(7262):703. [Medline].

  22. Wozniacki L, Zubilewicz T. Primary hyperhidrosis controlled with oxybutynin after unsuccessful surgical treatment. Clin Exp Dermatol. Dec 2009;34(8):e990-1. [Medline].

  23. Bouman HD, Lentzer EM. The treatment of hyperhidrosis of hands and feet with constant current. Am J Phys Med. Jun 1952;31(3):158-69. [Medline].

  24. Karakoç Y, Aydemir EH, Kalkan MT, Unal G. Safe control of palmoplantar hyperhidrosis with direct electrical current. Int J Dermatol. Sep 2002;41(9):602-5. [Medline].

  25. Murphy R, Harrington CI. Treating hyperhidrosis. Iontophoresis should be tried before other treatments. BMJ. Sep 16 2000;321(7262):702-3. [Medline].

  26. Sato K, Ohtsuyama M, Samman G. Eccrine sweat gland disorders. J Am Acad Dermatol. Jun 1991;24(6 Pt 1):1010-4. [Medline].

  27. Abell E, Morgan K. The treatment of idiopathic hyperhidrosis by glycopyrronium bromide and tap water iontophoresis. Br J Dermatol. Jul 1974;91(1):87-91. [Medline].

  28. Fujita M, Mann T, Mann O, Berg D. Surgical pearl: use of nerve blocks for botulinum toxin treatment of palmar-plantar hyperhidrosis. J Am Acad Dermatol. Oct 2001;45(4):587-9. [Medline].

  29. Moraru E, Voller B, Auff E, Schnider P. Dose thresholds and local anhidrotic effect of botulinum A toxin injections (Dysport). Br J Dermatol. Aug 2001;145(2):368. [Medline].

  30. Naumann M. Evidence-based medicine: botulinum toxin in focal hyperhidrosis. J Neurol. Apr 2001;248 Suppl 1:31-3. [Medline].

  31. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ. Sep 15 2001;323(7313):596-9. [Medline].

  32. Shelley WB, Talanin NY, Shelley ED. Botulinum toxin therapy for palmar hyperhidrosis. J Am Acad Dermatol. Feb 1998;38(2 Pt 1):227-9. [Medline].

  33. Swartling C, Farnstrand C, Abt G, Stalberg E, Naver H. Side-effects of intradermal injections of botulinum A toxin in the treatment of palmar hyperhidrosis: a neurophysiological study. Eur J Neurol. Sep 2001;8(5):451-6. [Medline].

  34. Schnider P, Binder M, Auff E, Kittler H, Berger T, Wolff K. Double-blind trial of botulinum A toxin for the treatment of focal hyperhidrosis of the palms. Br J Dermatol. Apr 1997;136(4):548-52. [Medline].

  35. Vadoud-Seyedi J, Simonart T. Treatment of axillary hyperhidrosis with botulinum toxin type A reconstituted in lidocaine or in normal saline: a randomized, side-by-side, double-blind study. Br J Dermatol. May 2007;156(5):986-9. [Medline].

  36. Flanagan KH, King R, Glaser DA. Botulinum toxin type a versus topical 20% aluminum chloride for the treatment of moderate to severe primary focal axillary hyperhidrosis. J Drugs Dermatol. Mar 2008;7(3):221-7. [Medline].

  37. Woolery-Lloyd H, Elsaie ML, Avashia N. Inguinal hyperhidrosis misdiagnosed as urinary incontinence: treatment with botulinum toxin A. J Drugs Dermatol. Mar 2008;7(3):293-5. [Medline].

  38. Naumann M, So Y, Argoff CE, et al. 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. Neurology. May 6 2008;70(19):1707-14. [Medline].

  39. Gregoriou S, Rigopoulos D, Chiolou Z, Papafragkaki D, Makris M, Kontochristopoulos G. Treatment of bromhidrosis with a glycine-soja sterocomplex topical product. J Cosmet Dermatol. Mar 2011;10(1):74-7. [Medline].

  40. Kumagai K, Kawase H, Kawanishi M. Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg. Aug 2005;80(2):461-6. [Medline].

  41. Kotzareff A. Resection partielle de trone sympathetique cervical droit pour hyperhidrose unilaterale. Rev Med Suisse Romande. 1920;40:111-3.

  42. Chen HJ, Lu K, Liang CL. Transthoracic endoscopic T-2, 3 sympathectomy for facial hyperhidrosis. Auton Neurosci. Oct 8 2001;93(1-2):91-4. [Medline].

  43. Hsu CP, Shia SE, Hsia JY, Chuang CY, Chen CY. Experiences in thoracoscopic sympathectomy for axillary hyperhidrosis and osmidrosis: focusing on the extent of sympathectomy. Arch Surg. Oct 2001;136(10):1115-7. [Medline].

  44. Kim BY, Oh BS, Park YK, Jang WC, Suh HJ, Im YH. Microinvasive video-assisted thoracoscopic sympathicotomy for primary palmar hyperhidrosis. Am J Surg. Jun 2001;181(6):540-2. [Medline].

  45. Panhofer P, Zacherl J, Jakesz R, Bischof G, Neumayer C. Improved quality of life after sympathetic block for upper limb hyperhidrosis. Br J Surg. May 2006;93(5):582-6. [Medline].

  46. Lai YT, Yang LH, Chio CC, Chen HH. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery. Jul 1997;41(1):110-3; discussion 113-5. [Medline].

  47. Chwajol M, Barrenechea IJ, Chakraborty S, Lesser JB, Connery CP, Perin NI. Impact of compensatory hyperhidrosis on patient satisfaction after endoscopic thoracic sympathectomy. Neurosurgery. Mar 2009;64(3):511-8; discussion 518. [Medline].

  48. Chou SH, Kao EL, Li HP, Lin CC, Huang MF. T4 sympathectomy for palmar hyperhidrosis: an effective approach that simultaneously minimzes compensatory hyperhidrosis. Kaohsiung J Med Sci. Jul 2005;21(7):310-3. [Medline].

  49. Heckmann M. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurgery. Jun 1998;42(6):1403-4. [Medline].

  50. Li X, Tu YR, Lin M, Lai FC, Chen JF, Miao HW. Minimizing endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: guided by palmar skin temperature and laser Doppler blood flow. Ann Thorac Surg. Feb 2009;87(2):427-31. [Medline].

  51. Kim WO, Kil HK, Yoon KB, Yoon DM. Topical glycopyrrolate for patients with facial hyperhidrosis. Br J Dermatol. May 2008;158(5):1094-7. [Medline].

  52. Goldman A, Wollina U. Subdermal Nd-YAG laser for axillary hyperhidrosis. Dermatol Surg. Jun 2008;34(6):756-62. [Medline].

  53. Lillis PJ, Coleman WP 3rd. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin. Jul 1990;8(3):479-82. [Medline].

  54. Na GY, Park BC, Lee WJ, Park DJ, Kim do W, Kim MN. Control of palmar hyperhidrosis with a new "dry-type" iontophoretic device. Dermatol Surg. Jan 2007;33(1):57-61. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.