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Hyperhidrosis - Management
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How should I manage someone with primary focal hyperhidrosis?

  • Provide advice about lifestyle measures and sources of information and support.
  • Recommend 20% aluminium chloride hexahydrate:
    • Driclor® and Anhydrol Forte® roll-ons are licensed, and can be prescribed or bought over-the-counter.
    • Odaban® spray is not a licensed medicinal product. However, it can be prescribed or bought over-the-counter.
    • Advise that aluminium chloride should be applied at night just before sleep:
      • To dry skin of the axillae, feet, hands, or face (avoiding the eyes), and should be washed off in the morning.
      • Every 1–2 days, as tolerated, until the condition improves.
      • And then, as required, which may be up to every 6 weeks.
    • Advise the person to avoid shaving for 24 hours before and after application.
    • Consider soaking lotion pads for application to the face.
    • For plantar hyperhidrosis, an aluminium salt dusting powder (Zeasorb®) can be used as an alternative to 20% aluminium chloride hexahydrate solution or spray.
    • Advise that skin irritation may occur. This can be managed by:
      • The use of topical emollients and soap substitutes.
      • A reduction in the frequency of application.
      • Giving a short course of 1% hydrocortisone cream, for up to 2 weeks.
    • Review 1–2 months after starting treatment. If successful, it can be continued indefinitely.
  • Consider treating any underlying anxiety, which may be an exacerbating factor:
    • Cognitive behavioural therapy may be preferable to antidepressants or propranolol, which can cause or worsen hyperhidrosis.
  • Refer to a dermatologist if the above measures are inadequate or unacceptable.
Additional information

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.
Basis for recommendation

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

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.

What advice should I give to someone with primary focal hyperhidrosis?

  • Recommend the following lifestyle measures:
    • For all people with primary focal hyperhidrosis:
      • Modify behaviour to avoid identified triggers (such as crowded rooms, caffeine, or spicy foods), where possible.
    • For people with primary axillary hyperhidrosis:
      • Use a commercial antiperspirant (as opposed to a deodorant) frequently.
      • Avoid tight clothing and manmade fabrics.
      • Wear white (as opposed to blue) shirts or black clothing to minimize the signs of sweating.
      • Consider using dress shields (also known as armpit or sweat shields) to absorb excess sweat and protect delicate or expensive clothing. These can be obtained via the internet or the Hyperhidrosis Support Group.
    • For people with primary plantar hyperhidrosis:
      • Wear moisture-wicking socks, changing them at least twice daily.
      • Use absorbent soles, and use absorbent foot powder twice daily.
      • Avoid occlusive footwear such as boots or sports shoes; wear leather shoes.
      • Alternate pairs of shoes on a daily basis to allow them to dry out fully before wearing them again.
    • For people with primary craniofacial hyperhidrosis:
      • Avoid food and drink triggers where possible, if they exacerbate symptoms (including caffeinated products, chocolate, spicy or sour foods, hot foods, alcohol, foods or drinks containing citric acid, or sweets).
  • Inform people about sources of information and support:
Basis for recommendation

How should I manage someone with suspected secondary focal or generalized hyperhidrosis?

  • Direct the history, examination, and investigations to look for an underlying cause, and manage appropriately. This will often require a referral to secondary care.
    • If a person has generalized hyperhidrosis, but symptoms and signs are non-specific, the following baseline investigations may be carried out in primary care in order to guide appropriate referral and management:
      • Full blood count.
      • Erythrocyte sedimentation rate or C-reactive protein.
      • Urea and electrolytes.
      • Liver function tests.
      • Random blood sugar tests.
      • Thyroid function tests.
      • Chest radiography.
      • Blood film for malarial parasites, if indicated.
      • HIV testing (after counselling), if indicated.
    • For people with suspected secondary focal hyperhidrosis, chest radiography may be useful to identify an intrathoracic neoplasm or a cervical rib.
Basis for recommendation
  • Recommendations are based on expert opinion from Guidelines for the primary care treatment and referral of focal hyperhidrosis [Lowe et al, 2003] and a US expert consensus statement, Recognition, diagnosis, and treatment of primary hyperhidrosis [Hornberger et al, 2004].

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Antiperspirant and dusting powder

Age from 12 years onwards
Aluminium chloride 20%: roll-on applicator (Driclor®/Anhydrol Forte®)
Aluminium chloride 20% solution
Roll on at night to affected areas, as required. Wash off the next morning.
Supply 60 ml.
Age: from 12 years onwards
NHS cost: £2.62
OTC cost: £4.50
Licensed use: yes
Patient information: Apply each night until sweating stops during the day, then decrease frequency of application to twice a week or less.
Aluminium chloride 20%: spray (Odaban®)
Aluminium chloride 20% spray
Spray on at night to affected areas, as required. Wash off the next day.
Supply 30 ml.
Age: from 12 years onwards
NHS cost: £3.83
OTC cost: £5.99
Licensed use: no
Patient information: Apply each night until sweating stops during the day, then decrease frequency of application to twice a week or less.
Chloroxylenol 0.5% + Aldioxa 0.22% dusting powder (Zeasorb®)
Chloroxylenol 0.5% / Aldioxa 0.22% powder
Apply to affected area(s) when required. Smooth powder over skin and between joints and folds.
Supply 50 grams.
Age: from 12 years onwards
NHS cost: £2.61
Licensed use: yes
Patient information: Wash and dry area thoroughly before application.

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