1 CPD credit: Therapeutic options in hyperhidrosis

Treatment should be tailored to disease location and severity. By Dr Zainab Laftah and Dr Rachael Morris-Jones


This article addresses the management options for primary hyperhidrosis (excessive sweating). Pharmacological therapies include topical and oral anticholinergic agents, iontophoresis and botulinum toxin injections. Surgical options should be limited to severe cases. A new treatment now available in the UK involves destruction of the eccrine glands in the axillae.

Key words

Clostridium botulinum, eccrine glands, excessive sweating, iontophoresis, microwave treatment, primary hyperhidrosis, secondary hyperhidrosis

Hyperhidrosis is a disorder of excessive sweating which is disproportionate to the physiological amount needed to maintain thermal homeostasis. It can lead to social embarrassment and occupational disability, often negatively affecting the patient's quality of life. It can be localised to a specific site (commonly, the axilla, palms and soles, or less commonly, the face or scalp), or generalised, affecting the entire skin. It can also be classified as primary (idiopathic) or secondary.

The diagnostic criteria for primary hyperhidrosis1 are outlined in box 1. Causes of secondary generalised hyperhidrosis (see box 2) should be excluded.

The prevalence of primary hyperhidrosis is 1% to 2.8%,2 although it is likely to be higher due to underreporting. It affects both sexes equally and can present at any age, although it usually begins in adolescence. Children commonly present with palmoplantar hyperhidrosis, while axillary hyperhidrosis is more commonly seen after the onset of puberty. Two-thirds of patients also report a positive family history.3

The pathogenesis of primary hyperhidrosis remains unclear, but is postulated to involve dysfunction of the cholinergic fibres of the sympathetic nervous system that innervate the eccrine glands.4

Axillary hyperhidrosis does not begin until puberty, reflecting development of apocrine glands, which continue to increase in size and number until late adolescence.

Primary hyperhidrosis can be exacerbated by stress, anxiety, heat, exercise, alcohol and spicy food. The term bromhidrosis refers to hyperhidrosis associated with an unpleasant odour caused by bacterial byproducts.


Excessive bilateral sweating for at least six months

Involving eccrine-dense sites (axillae, palms, soles and craniofacial)

Absent nocturnally

Episodes occurring at least weekly

Daily activities impaired

Absence of apparent secondary causes



Endocrine: hyperthyroidism, diabetes, phaeochromocytoma, carcinoid syndrome, acromegaly

Infective: acute bacterial or viral, malaria, TB

Drugs: alcohol, antidepressants, opioids

Neurological: gustatory sweating after parotidectomy, stroke

Other: malignancy, obesity, anxiety


Routine investigation should include FBC, renal function, LFT, TFT and random glucose to rule out any underlying disease.

For primary hyperhidrosis, a validated dermatology life quality index can be used initially to assess severity and monitor response to treatment, while the starch-iodine (Minor's) test can be used to measure sweat production.

The latter involves application of an iodine solution followed by cornstarch, which results in the production of a dark blue/black colour at sites of excessive sweating (figure 1).

Figure 1: Starch-iodine test for hyperhidrotic area in the axilla (Dr Zainab Laftah/King's College Hospital)

Pharmacological therapies

Topical agents

The main topical agents for axillary or palmoplantar hyperhidrosis are aluminium salts and generally, aluminium chloride 20% solution is used.

The mechanism of action is attributed to either a direct effect on the excretory eccrine gland epithelium, or mechanically obstructing the release of sweat.5

Treatment should initially be applied every night, on dry skin, and washed off in the morning, until efficacy is achieved, then used as required to maintain dryness.

The most commonly reported side-effect is skin irritation, likely related to the high salt concentration.

Newer topical preparations of 15% aluminium chloride with 2% salicyclic acid gel have improved tolerability. Skin irritation can also be reduced by applying 1% hydrocortisone the morning after treatment.

Topical 2% glycopyrrolate (glycopyrrolate bromide), an anticholinergic agent, can also be used, but is not licensed in the UK. It has been found to improve craniofacial hyperhidrosis, with effects lasting one to two days after application.6


The exact mechanism of action of iontophoresis remains unclear. However, it generates an electrical potential gradient that facilitates transdermal movement of solute ions, which is thought to lead to blockage of the sweat glands.7 Tap water or glycopyrrolate can be used and commercial units are available to facilitate treatment at home. Treatment is initially carried out every two to three days until a therapeutic effect is achieved, with maintenance every two to three weeks.

In comparison, botulinum toxin-A iontophoresis provides a longer duration of efficacy (up to three months), but its large molecular size poses a challenge, rendering it less favourable.8 Minor pain, erythema and burning are potential side-effects with iontophoresis. Contraindications include pregnancy and the presence of metallic implants, such as cardiac pacemakers and artificial orthopaedic joint/implants.

Oral agents

Anticholinergic agents (glycopyrrolate, propantheline bromide, oxybutynin) and alpha-adrenergic agonists (clonidine) are commonly used in clinical practice. The anticholinergics competitively inhibit acetylcholine at muscarinic receptors and trials have shown moderate improvement in two-thirds of patients with localised and generalised hyperhidrosis.9

The pharmacological actions of anticholinergics are not limited to sweat ducts and therefore these agents have central side-effects, which can be disabling and often limit their use. These include xerostomia, dizziness, blurring of vision, constipation, urinary hesitancy/retention, tachycardia and rarely, confusion. These agents should be used cautiously in patients with bladder outflow obstruction, gastro-oesophageal reflux disease, glaucoma or cardiac insufficiency.

Glycopyrronium is thought to be more efficacious and has fewer side-effects than other anticholinergics. This is attributed to its inability to cross the blood/brain barrier and subsequent minimal effect on the CNS.

Propantheline is the only anticholinergic licensed for use in gustatory hyperhidrosis.

Clonidine, an antihypertensive agent, enhances the function of alpha-adrenergic receptors, thus inhibiting sympathetic output. It has a similar side-effect profile to the anticholinergic agents and can also result in hypotension.9

Beta-blockers (propranolol) and calcium-channel blockers (diltiazem) have also been trialled for hyperhidrosis. The starting dose of oral agents is initially low and then increased in accordance to efficacy and tolerability.

Botulinum toxin injections

Clostridium botulinum is a Gram-positive anaerobe that produces a neurotoxin which binds irreversibly at the presynaptic membrane and inhibits the release of acetylcholine, blocking the sweat glands. A large meta-analysis demonstrated 75-100% efficacy for axillary and palmar hyperhidrosis.10

A Minor's test can be used to visualise the hyperhidrotic area before gridlines are drawn on the affected region to aid even distribution of injections. Botulinum-A toxin is most commonly used and 50 units are injected intradermally into each axilla (figure 2), with efficacy lasting seven to 12 months.11

It is well tolerated, apart from the mild discomfort associated with multiple injections and compensatory sweating (5-10%) in parts of the body unrelated to location of treatment.5

A high dose (100 units) is required to treat palmoplantar hyperhidrosis, which can be painful and requires administration under a peripheral nerve block. The efficacy is four to six months and small muscle wasting and weakness have been reported.11 Contraindications include pregnancy and neuromuscular diseases, such as myasthenia gravis.

Figure 2: Grid aids distribution of botulinum toxin into the axilla (Dr Zainab Laftah/King's College Hospital)


MiraDry is a new and promising non-surgical treatment modality to treat axillary hyperhidrosis. It uses microwave technology to irreversibly destroy sweat glands.

The dermis is initially anaesthetised. The MiraDry handpiece is then placed on the affected area and microwaves preferentially target the eccrine glands at the interface of the deep dermis and subcutis, leading to localised thermolysis.12

Efficacy is 90% at two years (two treatments three months apart), with histological findings following the intervention suggesting potential long-term effects through destruction of the eccrine glands.13

Short-term adverse effects are minor and include erythema, bruising and oedema, which can be reduced by taking preand post-treatment ibuprofen and using icepacks. Partial alopecia of axillary hair and altered sensation have also been reported.

Although data regarding long-term safety is still emerging, this non-invasive, tolerable therapy has shown promising results. The cost of lifetime treatment with botulinum toxin for axillary hyperhidrosis is likely to be higher than one or two treatments using MiraDry.

Surgical options

Surgical options should be limited to severe cases that are recalcitrant to the treatment modalities discussed above, because of the associated risks of complications.

Retrodermal curettage/liposuction

These techniques involve initially creating a small incision in the skin, then undermining and using curettage or liposuction to remove the retrodermal sweat glands. Both have satisfying results (80-90%) with permanent efficacy, although recurrence (8%) has been reported.14 Immediate postoperative complications include pain, bleeding, haematoma, infection and skin necrosis. Long-term adverse effects are scarring, wound contractures and impaired arm mobility.15

Endoscopic thoracic sympathectomy

Endoscopic thoracic sympathectomy (ETS) is currently the surgical gold standard treatment for palmar hyperhidrosis and recent studies have demonstrated clinical success for axillary hyperhidrosis.16 ETS involves interruption of nerve impulse transmissions from fibres in the upper dorsal sympathetic chain (ganglions T2 to T4), which supply the sweat glands.

Postoperative complications include haematoma, swelling, pain and, rarely, phrenic nerve damage or Horner's syndrome (<1%). The most troublesome long-term adverse effect is compensatory sweating, which can occur in 86-100% of cases. Pneumothorax occurs in up to 75% of patients but usually resolves spontaneously.17 Case reports describe high levels of satisfaction and abolition of compensatory hyperhidrosis for up to 10 months with botulinum-A toxin.18 Similar effects, although short-lived, are seen with 2% glycopyrrolate solution.19


Treatment approaches should be based on the site and severity of the hyperhidrosis. Suggested stepwise management for patients aged 12 years or older, according to published recommendations,20,21 is outlined in table 1.

Axillary hyperhidrosis Palmar hyperhidrosis  Plantar hyperhidrosis  Craniofacial hyperhidrosis

Topical aluminium chloride

Botulinum-A toxin injections

Oral anticholinergics


 Local surgery/ETS

Topical aluminium chloride


Oral anticholinergics

Botulinum-A toxin injections

Local surgery/ETS


Topical aluminium chloride


Oral anticholinergics

Botulinum-A toxin injections


Topical aluminium chloride/topical glycopyrrolate

Oral anticholinergics

Botulinum-A toxin injections

Local surgery/ETS


Primary hyperhidrosis is a common disorder, associated with significant psychosocial impact. Numerous therapies, with varying efficacy and adverse effects, are available and treatment is tailored according to location and severity.

MiraDry, a novel microwave technology device, has proved its efficacy and safety in a randomised, blinded multicentre study.22 This non-invasive therapy may have a greater role in the future management of patients with hyperhidrosis.

  • Dr Zainab Laftah is dermatology registrar, and Dr Rachael Morris-Jones is dermatology consultant, at King's College Hospital, London

Competing interests: None declared


1. Walling HW. Clinical differentiation of primary from secondary hyperhidrosis. J Am Acad Dermatol 2011; 64(4): 690-5.

2. Strutton DR, Kowalski JW, Glaser DA et al. US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004; 51(2): 241-8.

3. Ro KM, Cantor RM, Lange KL et al. Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg 2002; 35(2): 382-6.

4. Solish N, Bertucci V, Dansereau A et al. A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee. Dermatol Surg 2007; 33(8): 908-23.

5. Lowe NJ, Glaser DA, Eadie N et al. Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. J Am Acad Dermatol 2007; 56(4): 604-11.

6. Kim WO, Kil HK, Yoon KB et al. Topical glycopyrrolate for patients with facial hyperhidrosis. Br J Dermatol 2008; 158(5): 1094-7.

7. Collin J, Whatling P. Treating hyperhidrosis. Surgery and botulinum toxin are treatments of choice in severe cases. BMJ 2000; 320(7244): 1221-2.

8. Davarian S, Kalantari KK, Rezasoltani A et al. Effect and persistency of botulinum toxin iontophoresis in the treatment of palmar hyperhidrosis. Australas J Dermatol 2008; 49(2): 75-9.

9. Walling HW. Systemic therapy for primary hyperhidrosis: a retrospective study of 59 patients treated with glycopyrrolate or clonidine. J Am Acad Dermatol 2012; 66(3): 387-92.

10. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ 2001; 323(7313): 596-9.

11. Campanati A, Penna L, Guzzo T et al. Quality-of-life assessment in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study. Clin Therapeut 2003; 25(1): 298-308.

12. Hong HC, Lupin M, O'Shaughnessy KF. Clinical evaluation of a microwave device for treating axillary hyperhidrosis. Dermatol Surg 2012; 38(5): 728-35.

13. Lupin M, Hong HC, O'Shaughnessy KF. Long-term efficacy and quality of life assessment for treatment of axillary hyperhidrosis with a microwave device. Dermatol Surg 2014; 40(7): 805-7.

14. Rompel R, Scholz S. Subcutaneous curettage vs. injection of botulinum toxin A for treatment of axillary hyperhidrosis. J Eur Acad Dermatol Venereol 2001; 15(3): 207-11.

15. Proebstle TM, Schneiders V, Knop J. Gravimetrically controlled efficacy of subcorial curettage: a prospective study for treatment of axillary hyperhidrosis. Dermatol Surg 2002; 28(11): 1022-6.

16. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery 2002; 51(5 Suppl): S84-7.

17. Ojimba TA, Cameron AE. Drawbacks of endoscopic thoracic sympathectomy. Br J Surg 2004; 91(3): 264-9.

18. Santana-Rodriguez N, Clavo-Varas B, Ponce-Gonzalez MA et al. Primary frontal hyperhidrosis successfully treated with low doses of botulinum toxin A as a useful alternative to surgical treatment. J Dermatol Treat 2012; 23(1): 49-51.

19. Cladellas E, Callejas MA, Grimalt R. A medical alternative to the treatment of compensatory sweating. Dermatol Ther 2008; 21(5): 406-8.

20. Hornberger J, Grimes K, Naumann M et al. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol 2004; 51(2): 274-86.

21. Hoorens I, Ongenae K. Primary focal hyperhidrosis: current treatment options and a step-by-step approach. J Eur Acad Dermatol Venereol 2012; 26(1): 1-8.

22. Johnson JE, O'Shaughnessy KF, Kim S. Microwave thermolysis of sweat glands. Lasers Surg Med 2012; 44(1): 20-5.


 These further action points allow you to earn more credits by increasing the time spent and the impact achieved

Present a summary of treatment options for primary hyperhidrosis to your colleagues

Audit patients in your practice with hyperhidrosis and consider whether any of them would benefit from receiving a different treatment option

Investigate clinics offering the MiraDry procedure and see if you can arrange a visit to observe the treatment in use

Save this article and add notes with your free online CPD organiser

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