The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options

J Am Acad Dermatol. 2019 Sep;81(3):669-680. doi: 10.1016/j.jaad.2018.11.066. Epub 2019 Jan 31.


Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.

Keywords: BTX; aluminum chloride hexahydrate; botulinum neurotoxin; botulinum toxin; compensatory sweating; endoscopic sympathectomy; fractional microneedle radiofrequency; hyperhidrosis; injectable therapy; iontophoresis; laser therapy; microwave thermolysis; oral anticholinergics; topical antiperspirants; ultrasound technology.

Publication types

  • Review

MeSH terms

  • Administration, Cutaneous
  • Antiperspirants / therapeutic use
  • Botulinum Toxins, Type A / administration & dosage
  • Cholinergic Antagonists / administration & dosage
  • Cognitive Behavioral Therapy
  • Combined Modality Therapy / methods
  • Curettage
  • Humans
  • Hyperhidrosis / etiology
  • Hyperhidrosis / psychology
  • Hyperhidrosis / therapy*
  • Injections, Subcutaneous
  • Iontophoresis
  • Microwaves / therapeutic use
  • Quality of Life*
  • Radiofrequency Ablation
  • Sweat Glands / physiopathology
  • Sweat Glands / radiation effects
  • Sweat Glands / surgery*
  • Sweating / physiology
  • Sweating / radiation effects
  • Sympathectomy
  • Treatment Outcome
  • Ultrasonic Therapy


  • Antiperspirants
  • Cholinergic Antagonists
  • Botulinum Toxins, Type A