7th June 2025

Management

Treatment is dependent on the cause of hyperhidrosis. Secondary hyperhidrosis is managed by treating the underlying cause. For management of primary focal hyperhidrosis, it is as follows:

• Minimise exposure to identified triggers
• Self-care management strategies: 
  • Primary axillary hyperhidrosis – commercial antiperspirant, avoid tight clothing and man-made fabrics, white/black clothing to minimise sweating signs, armpit or sweat shield to absorb excess moisture 
  • Primary plantar hyperhidrosis – moisture wicking socks, absorbent soles, absorbent foot powder, alternate shoes daily, avoid occlusive footwear 
• 20% aluminium chloride hexahydrate preparations as roll-on antiperspirant and spray for symptom relief (must be applied when skin is dry to minimise potential for irritation)
  • If skin irritation occurs, reduce frequency of application, hydrocortisone 1% cream for 2 weeks, topical emollients and soap substitutes 
  • Review in 6 weeks and continue long-term if effective 
• Identify any anxiety and manage as needed
  • Selective serotonin reuptake inhibitors and propranolol can worsen symptoms 
• Referral to dermatologist if above not effective or tolerated

Specialist treatment 

• Oral and topical treatment 
  • Topical glycopyrrolate (antimuscarinic) for primary craniofacial hyperhidrosis (off-label indication) 
  • Oral antimuscarinic (propantheline, oxybutynin, glycopyrronium bromide [off label indication; the latter may be difficult to procure])
    • Often limited by adverse effects such as dry mouth, blurred vision, constipation, urinary retention
• Iontophoresis (for palmoplantar sweating)
  • Hyperhidrosis site immersed in warm water through which weak electric current is passed 
  • Introduces charged ion into skin which inhibits function of sweat gland in that area 
  • If unsuccessful or in severe cases, glycopyrronium bromide added to water 
  • Every 1-4 weeks
  • Adverse effects – transient discomfort, erythema, vesicle formation at treatment site 
• Botulinum A toxin (mostly used for axillae)
  • Multiple intradermal injection to hyperhidrosis area 
  • Inhibiting acetylcholine release from sympathetic cholinergic nerve terminals that innervate sweat glands 
  • Lasts 6-9 months 
  • Adverse effects – pain during injection, compensatory sweating 
• Surgery 
  • Localised curettage or resection of axillary eccrine sweat glands under local anaesthesia 
  • Endoscopic thoracic sympathectomy if other measures unsuccessful 
    • Division of sympathetic chain over the neck of the ribs in pleural cavity under general anaesthesia 
    • Prevent transmission nerve signals from sympathetic ganglia to fibres innervating areas producing excess sweat 
    • Indications – severe palmar, axillary or craniofacial hyperhidrosis 
    • Complications – compensatory hyperhidrosis elsewhere, gustatory sweating, pneumothorax, atelectasis, significant bleeding, recurrence