Recommend or prescribe 20% aluminium chloride hexahydrate in alcohol solution.

• CKS found no randomized, placebo-controlled trials of the efficacy and safety of aluminium chloride hexahydrate, or any other aluminium salts for the treatment of primary focal hyperhidrosis.
• The recommendation to use 20% aluminium chloride hexahydrate in alcohol solution as first-line treatment of primary focal hyperhidrosis is based on poor quality evidence from two small, quasi-controlled trials [Rayner et al, 1980; Goh, 1990]; four case series of between 12 and 65 highly selected subjects [Scholes et al, 1978; Ellis and Scurr, 1979; Jensen and Karlsmark, 1980; Glent-Madsen and Dahl, 1988]; and expert opinion, including two published consensus statements [Hornberger et al, 2004; Solish et al, 2007], two guidelines [Lowe et al, 2003; International Hyperhidrosis Society, 2008b], and an evidence-based review [DTB, 2005].
• Prescribing advice is based on expert opinion from Guidelines for the primary care treatment and referral of focal hyperhidrosis [Lowe et al, 2003] and CKS external reviewers' comments.

Consider treating any underlying anxiety which may be an exacerbating factor.

• CKS found no trials of the efficacy of treating anxiety for people with primary focal hyperhidrosis. Treatment of underlying anxiety is recommended on the basis of expert opinion that focal hyperhidrosis can be exacerbated by emotional stimuli, expressed in published review articles [Cheung and Solomon, 2002; Hornberger et al, 2004; Solish et al, 2008] and by expert reviewers.
• A systematic review of psychological interventions for primary hyperhidrosis also found no controlled trials [Kennard and Lopez, 2004]. Two small case-control studies and four small case series were identified, which suggested some benefits from relaxation and biofeedback.
• Cognitive behavioural therapy (CBT) is recommended over antidepressants or propranolol on the basis of expert opinion and common sense:
• CBT is recommended as a first-line treatment of anxiety in current guidelines published by the National Institute for Health and Clinical Excellence [NICE, 2007].
• CBT is recommended as a treatment for primary focal hyperhidrosis 'where anxiety is thought to be the predominant cause' in a 10 minute consultation review article, published in the British Medical Journal (expert opinion) [Piercy, 2005].
• Antidepressants and propranolol can cause or exacerbate sweating. Meta-analyses have found that between 8.6% and 14% of people taking antidepressants experience increased sweating, the highest incidence being seen with venlafaxine and the lowest with trazodone and fluvoxamine [DTB, 2005; Cheshire and Fealey, 2008].

Refer to a dermatologist if the above measures are inadequate or unacceptable.

• This recommendation is based on expert opinion from Guidelines for the primary care treatment and referral of focal hyperhidrosis [Lowe et al, 2003], on the basis that other treatments require additional expertise or equipment only likely to be found in secondary care.

Treatments in secondary care (in Additional information).

• Descriptions of possible secondary care treatments are mainly derived from Guidelines for the primary care treatment and referral of focal hyperhidrosis [Lowe et al, 2003], an evidence-based review [DTB, 2005], US and Canadian expert consensus statements [Hornberger et al, 2004; Solish et al, 2007], and internet-based guidelines [International Hyperhidrosis Society, 2008b].
• Details of the availability of topical glycopyrrolate are from a letter by UK consultant dermatologists published in the British Journal of Dermatology [Kavanagh et al, 2006].
• The statement that botulinum toxin is not always available at NHS hospitals, and is mostly given in private clinics, is made on the Hyperhidrosis Support Group website, and expert reviewers have also identified the variation in NHS funding.
• Complication rates of endoscopic thoracic sympathectomy are from an evidence-based review [Ojimba and Cameron, 2004].
• The quality of trial evidence for the listed secondary care treatments varies depending on the individual treatment, and is often based on expert opinion. Whilst there is evidence of the efficacy and safety (when performed by trained healthcare professionals) of botulinum toxin for primary axillary hyperhidrosis from four randomized, controlled trials, including nearly 1000 people, the evidence for other treatments is from small controlled trials, case series, or expert opinion.