Hyperhidrosis treatment: solutions for a common problem

Hyperhidrosis is a medical condition in which you sweat excessively. Sweating is a necessary and natural response to an increase in body temperature; when your body senses a temperature rise, it triggers your autonomic nervous system (sympathetic nerves) to help you cool off. Several things can trigger sweating, including warm temperatures, exercise, or feelings of anger, embarrassment, nervousness, or fear. In hyperhidrosis, you sweat more than usual, even without the typical triggers. Approximately 4.8% of the population in the United States (that’s 15.3 million people) suffer from hyperhidrosis (Doolittle, 2016).

The two types of hyperhidrosis are primary focal hyperhidrosis and secondary generalized hyperhidrosis. In primary hyperhidrosis, excessive sweating is the medical condition; the problem is not caused by another medical condition or medications that you may be taking. Primary hyperhidrosis often focuses on specific parts of the body, the most common focal areas being hands, feet, underarms, and face/head. Primary hyperhidrosis usually begins in childhood or adolescence and occurs equally on both sides of the body. These sweating episodes often happen at least once a week, but rarely happen during sleep. It seems that there is a genetic component to this condition as most people with primary hyperhidrosis also have a family member with excessive sweating.

However, in secondary hyperhidrosis, sweating is caused by another medical condition (like hyperthyroidism or menopause) or medication side effects. This type of hyperhidrosis usually affects larger areas, also called "generalized" areas, of the body; some people complain of sweating “all over.” Secondary hyperhidrosis typically starts in adulthood and does occur during sleep (night sweats).

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As we’ve mentioned, surveys indicate that almost 5% of the population in the U.S. has hyperhidrosis; however, this number is likely to be lower than the actual prevalence because many people never mention it to their healthcare provider. Most people don’t realize that their excessive sweating is a medical problem, or that it is treatable. There are a variety of treatments available, and discussing the pros and cons of each with your provider is the best way to find the right one for you. Potential therapies include over-the-counter antiperspirants, prescription antiperspirants, botulinum toxin injections, iontophoresis, anticholinergic medication, and surgery; these can be used individually or in combination.

Over-the-counter antiperspirants are the first-line treatment for unwanted perspiration. It is important to note that there is a difference between an antiperspirant and a deodorant. An antiperspirant contains metallic salts, like aluminum chloride, aluminum chlorohydrate, and aluminum zirconium salts; after being applied to the skin, these compounds get mixed with perspiration, are drawn into the sweat duct, and then plug up the duct, preventing further sweating. Deodorants, by themselves, don't prevent sweating; they just reduce odor. The International Hyperhidrosis Society recommends using these products morning and evening, taking care to apply to dry skin and consider gently massaging the product into your skin (IHhS, 2019). Spray antiperspirants can be used as well, especially for hyperhidrosis of the feet (plantar hyperhidrosis). The benefits of this treatment are the relatively low cost and ease of access and use. Over-the-counter antiperspirant cons include skin irritation and the chance that they may not work for people with more than mild sweating issues. If these products are not sufficient, you can talk to your provider about prescription antiperspirants. These products typically contain higher concentrations of aluminum chloride, anywhere from 10–30%. While effective, the main drawback of prescription antiperspirants is skin irritation.

Botulinum toxin (brand name Botox) is another treatment option that has been successful for many people. It is approved by the U.S. Food and Drug Administration (FDA) for the treatment of excessive armpit sweating (axillary hyperhidrosis). While it is not FDA-approved for use in other areas, studies have shown that botulinum toxin can also treat increased sweating in hands and feet (palmar hyperhidrosis and plantar hyperhidrosis). Botulinum toxin works by temporarily blocking the secretion of acetylcholine, the chemical responsible for triggering sweating. It takes about two to four days for botulinum toxin to start taking effect, and the dryness usually lasts 4–6 months; some people report up to a year of effectiveness, especially after repeated injections (AAD, 2019). The main benefit of this treatment is the long-term effectiveness; the downside is the potential for temporary muscle weakness in the first few days after injection, and the need for repeated injections as the effects are not permanent.

If you have hyperhidrosis in your hands or feet (or both), iontophoresis may improve your symptoms. To perform this treatment, which you can do at home, you will need to submerge your hands or feet in a shallow pan of tap water; the iontophoresis medical device will then send a low-voltage electric current through the water to the sweat glands in your hands (or feet). This current temporarily shuts down the sweat glands in the treated areas. It typically takes a total of 6-10 treatments for the sweat glands to respond; each treatment is 20-40 minutes, and you will likely need to have 2-3 treatments a week. Once you get your desired results, you may need to repeat the procedure weekly or monthly to maintain the effects. The benefits of this treatment are that, with maintenance, this can give you long term positive results. The cons are the time commitment involved in the initial treatments and the need for maintenance; some people also report dry skin, irritation, or mild discomfort with the therapy. Also, you should avoid iontophoresis if you are pregnant, have a pacemaker, or have a cardiac condition or epilepsy. Talk to your healthcare provider before considering this treatment to see if it is appropriate for you.

Another treatment option is oral prescription anticholinergic medication, like oxybutynin and glycopyrrolate; because these are oral medications, they treat overall sweating and cannot target specific areas. These drugs act to stop acetylcholine from reaching the sweat glands and triggering sweating. Several side effects have been reported, the most common being dry mouth, at a rate of 38-73% of people using these drugs (McConaghy, 2018). Other side effects include blurry vision, constipation, difficulty urinating, fast heart rate, and drowsiness; in several studies, approximately 10% of people stopped the treatment because of the side effects (Cruddas, 2017). Because of the high rate of side effects, anticholinergic medications are generally only prescribed if other therapies are unsuccessful.

Because it is the most invasive option, surgery is often the treatment of last resort. There are two surgical options: removal of the sweat glands and cutting the sympathetic nerves to the area (endoscopic thoracic sympathectomy). Removal of the sweat glands is only done in the underarm area (local surgery) and can be performed in your dermatologist’s office. Only the area to be treated is numbed, and your one or more of the following techniques are used to surgically remove the sweat glands:

• Excision-cut out the sweat glands

• Liposuction-remove the glands with suction; this is sometimes also combined with curettage

• Curettage-scrape out the sweat glands

• Laser surgery-use high energy light waves to vaporize sweat glands

Regardless of the technique used, there are always risks associated with surgery, including infection, bruising, swelling, and loss of sensation in the underarm area. There is no associated compensatory sweating (see below) after the surgical removal of the sweat glands.

The other surgical option is to sever the sympathetic nerves that are feeding the areas of excessive sweating, a procedure known as endoscopic thoracic sympathectomy (ETS). This is the most invasive of the treatments, requiring general anesthesia and surgery performed in the hospital. Endoscopic thoracic sympathectomy involves cutting or clipping the sympathetic nerves in the thoracic spine (the torso) to treat excessive sweating in hands, feet, or underarm area. While it does decrease the sweating in the treated areas, it is associated with the adverse effect of compensatory sweating. In compensatory sweating, your body sweats in other parts to compensate for no longer being able to sweat in the treated areas; for some people, the compensatory sweating is worse than the original hyperhidrosis.

In addition to the treatments listed, you can also try to reduce sweating by:

• Bathing daily to decrease the bacteria on your skin and drying yourself off thoroughly

• Wearing shoes and socks made of natural materials that allow your feet to breath

• Changing your socks often if you have sweaty feet

• Airing out your feet when you can

• Wearing clothes made of natural or moisture-wicking fabrics

If you have hyperhidrosis, you are not alone. Fortunately, a variety of treatments exist for the full range of severity of excessive sweating. Talk to your healthcare provider about your sweating issues, especially if you are avoiding certain situations or under significant distress because of them. Together, you will find the best treatment path to follow.

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Current version

December 19, 2019

Written by

Chimene Richa, MD

Fact checked by

Mike Bohl, MD, MPH, ALM

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About the medical reviewer

Mike Bohl, MD, MPH, ALM

Dr. Mike is a licensed physician and a former Director, Medical Content & Education at Ro.