Management of Primary Focal Hyperhidrosis: An Algorithmic Approach

May 2021 | Volume 20 | Issue 5 | Original Article | 523 | Copyright © May 2021

Published online April 22, 2021

Vivian Liu BSa, Mehdi Farshchian MD PhDb, Geoffrey A. Potts MDb

aWayne State University School of Medicine, Detroit, MI
bDepartment of Dermatology, Wayne State University, Dearborn, MI

Hyperhidrosis (HH) is defined as perspiration beyond the level required to maintain temperature regulation. HH affects nearly 4.8% of the population in the United States. It can have a great impact on patient’s quality of life by disturbing daily activity, performance, confidence, social interactions, and mental health. In the majority of patients with HH (93%), the etiology of excess sweating is idiopathic, which classifies it as primary focal HH. Mild HH may be controlled with topical antiperspirants and lifestyle modifications. Based on the location of involvement, iontophoresis and botulinum toxin may be considered if the patient does not respond to topical therapies. Despite minimizing sweating, chronic use of systemic anticholinergics, in particular oxybutynin, may result in detrimental adverse effects such as dementia. Local surgery, radiofrequency, microwave, and lasers are other potential modalities for HH. Sympathectomy can be a last resort for the treatment of focal HH of the palmar, plantar, axillary, and craniofacial areas after failure of less invasive therapeutic options. In this review, we conducted a comprehensive search in the PubMed electronic database to summarize an algorithmic approach for the treatment of HH. This can help broaden options for managing this difficult disease.

J Drugs Dermatol. 20(5):523-528. doi:10.36849/JDD.5774


Hyperhidrosis (HH) is a disorder of excessive perspiration that exceeds the level required for physiological temperature regulation. Sweat is produced by both eccrine and apocrine glands in the skin. Eccrine sweat glands are responsible for the majority of sweat production and thermal regulation, while apocrine glands are mainly responsible for the odor produced when sweating. HH is primarily due to eccrine gland hyperactivity. In 93% of cases of HH, the etiology is unknown, which classifies it as primary idiopathic HH. Secondary HH is caused by another underlying condition or medication. Primary focal HH typically involves the face, axillae, palms, and/or soles.1 Primary HH affects approximately 4.8% of the population in the United States.2 Excessive sweating may pose significant strain on an individual’s daily activities. It may increase risk for cutaneous infection, dermatitis, or disrupt social life, alter sense of wellbeing, and harm emotional/mental health.3,4 Identified treatment modalities for HH, which will be discussed in this review, are topical and systemic treatments, iontophoresis, botulinum toxin (BTX), radiofrequency microneedling, microwave thermolysis, and surgical procedures.


A literature search was performed in the PubMed electronic database using “primary hyperhidrosis” and “treatment” as key words. The search was limited to articles published in English language journals from 2015 until June 2020. The details of article selection and exclusion criteria are shown in Figure 1. Outcome measures were study design, number of subjects, length of treatment, treatment response, and adverse effects.