Treatments in secondary care

• Modified topical therapy:
• Emollients, topical corticosteroids, different strengths of aluminium salts (up to 50%), and topical glutaraldehyde or formaldehyde may be used.
• Topical glycopyrrolate (an antimuscarinic agent) can be prepared by special order manufacturers, and may be useful for primary craniofacial hyperhidrosis.
• Iontophoresis:
• In tap water iontophoresis, the sites of hyperhidrosis are immersed in warm water (or a wet contact pad may be applied) through which a weak electric current is passed.
• If unsuccessful, glycopyrronium bromide (an antimuscarinic agent) can be added to the water, but adverse effects are common.
• It is usually performed in hospital, but home treatment kits (using tap water) can be purchased for £250 to £500.
• Treatment usually consists of 2–4 treatment sessions per week. Each treatment session lasts 20–30 minutes. Improvement usually occurs after 4–10 sessions.
• Maintenance treatment is typically required at intervals of 1–4 weeks.
• No serious adverse effects are reported for tap water iontophoresis, but it is only suitable for the hands, feet and, less easily, the axillae.
• Botulinum toxin:
• Botulinum toxin is delivered by multiple intradermal injections to the affected areas.
• Botox^® is licensed for the treatment of axillary hyperhidrosis; botulinum toxin can also be helpful for palmar, plantar, and craniofacial hyperhidrosis but the procedure may be more difficult and painful at these sites.
• Adverse effects include compensatory sweating (5–10%) and injection-site pain or reactions (9–12%). Transient muscle weakness and loss of fine motor control, as well as anaphylaxis, have been reported, and transmission of infectious agents is theoretically possible.
• It is not always available at NHS hospitals, and is mostly given in private clinics.
• Surgery:
• Resection of sweat glands can be carried out using local anaesthesia and is useful for small areas of axillary hyperhidrosis.
• Endoscopic thoracic sympathectomy (ETS):
• This involves video-assisted laparoscopic division of the sympathetic chain over the neck of the ribs under general anaesthesia, usually by a vascular surgeon.
• ETS is indicated (as a last resort) for severe palmar, axillary, and sometimes craniofacial hyperhidrosis. Lumbar sympathectomy is not used for plantar hyperhidrosis because of the risk of sexual dysfunction.
• Complications include: compensatory hyperhidrosis (very common, up to 100%), gustatory sweating (common, up to 50%), rhinitis (quite common, up to 10%), pneumothorax (common, up to 75%, but usually resolves spontaneously), significant bleeding (up to 5%), Horner's syndrome (rare, < 1%), and phrenic nerve damage (extremely rare).
• Other treatments that may be used:
• Oral antimuscarinics, such as glycopyrronium bromide (which needs to be imported) and oxybutinin, may be used, but their use is limited by adverse effects.
• Clonidine.
• Diltiazem.
• Benzodiazepines.