The Treatment of Primary Focal Hyperhidrosis

Todd Wechter, BSc; Steven R. Feldman, MD, PhD; Sarah L. Taylor, MD, MPH

Skin Therapy Letter. 2019;24(1)

Methods

A review of the literature was performed utilizing multiple databases, including PubMed, ClinicalTrials.gov and Google Scholar. Search criteria included general terms such as, "Hyperhidrosis therapy" and "Hyperhidrosis treatment", as well as more specific terms relating to each respective therapy.

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Table 1. Summary of literature review for hyperhydrosis treatments.
Type	Treatment	Mechanism of Action	Summary	Side Effects
Topical Therapies	Aluminum chloride antiperspirants	Precipitates and blocks sweat gland ducts	An effective initial option, although many patients require additional forms of treatment. Requires continued use.	Local skin irritation.
Topical Therapies	Topical anticholinergics	Competitive inhibition of acetylcholine	Can be used as an alternative topical option. Studies of topical anticholinergic medications have been promising, although additional research is needed.	General anticholinergic effects (i.e. dry mouth, vision changes, acute closed angle glaucoma, decreased intestinal motility, urinary retention). Possible cognitive impairment with long-term use.
Local Non-Surgical Therapies	Iontophoresis	Unknown	A great treatment option for palmoplantar disease with minimal side effects. Can also be used to deliver other medications through the skin.	Local skin irritation and burns.
Local Non-Surgical Therapies	Botulinum toxin A	Prevents acetylcholine release into the synapse	An extremely effective treatment option for all disease locations. Requires multiple treatments, although symptomatic relief may be prolonged with repeated injection sessions. Less painful delivery methods are being investigated.	Pain at injection site, phantom sweating, reversible muscle weakness.
Emerging Procedural Interventions	Microwave thermolysis	Destroys sweat glands	Provides symptomatic relief and may have long-term efficacy. Is a noninvasive but expensive treatment option.	Pain, swelling, local skin irritation, transient subcutaneous nodules, reversible neuropathy.
	Laser therapy	Destroys sweat glands	Nd:YAG laser therapy is an effective, minimally invasive treatment option. Diode laser therapy (800 nm) requires additional investigation.	Nd:YAG: Swelling, burns, transient neuropathy, transient axillary hair loss. Diode laser (800 nm): Transientaxillary skin depigmentation.
	Focused ultrasound	Destroys sweat glands	An effective therapy that may provide long-term symptomatic relief. Additional research is needed.	Pain, paresthesia, bruising, blistering, seroma formation, hyperpigmentation.
Surgical Management	Local surgical treatment (suction curettage, local excision)	Destroys and/or removes sweat glands	Generally effective, although very invasive treatment options.	Pain, bruising, bleeding, swelling, scaring, infection.
Surgical Management	Sympathectomy	Interrupts sympathetic outflow to sweat glands	An effective but invasive surgical treatment that provides long-term symptomatic relief. More effective for palmar disease than axillary disease. Compensatory sweating is its major limitation.	Pneumothorax, Horner's syndrome, neuropathy, subcutaneous emphysema, bradycardia and other surgical risks.
Systemic Therapy	Oral anticholinergics	Competitive inhibition of acetylcholine	Generally effective treatment options with reasonable side effect profiles.	General anticholinergic effects (i.e. dry mouth, vision changes, acute closed angle glaucoma, decreased intestinal motility, urinary retention). Possible cognitive impairment with long-term use.

Table 2. Summary of our treatment recommendations based on disease location and severity.
Disease Location	Recommendations
Disease Location	Mild to Moderate Disease	Severe Disease
Axillary	1st line: Topical antiperspirant 2nd line: BTX-A injection 3rd line: Topical or oral anticholinergics	1st line: Topical antiperspirant 2nd line: BTX-A injection 3rd line: Topical or oral anticholinergics 4th line: Microwave thermolysis, Nd:YAG laser or focused ultrasound 5th line: Suction curettage 6th line: Sympathectomy
Palmoplantar	1st line: Topical antiperspirant 2nd line: Iontophoresis 3rd line: BTX-A injection 4th line: Topical or oral anticholinergics	1st line: Topical antiperspirant 2nd line: Iontophoresis 3rd line: BTX-A injection 4th line: Topical or oral anticholinergics 5th line: Sympathectomy (only if palmar involvement)
Craniofacial	1st line: Topical antiperspirant 2nd line: BTX-A injection 3rd line: Topical or oral anticholinergics	1st line: Topical antiperspirant 2nd line: BTX-A injection 3rd line: Topical or oral anticholinergics 4th line: Sympathectomy

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