Management Strategies Of Palmar Hyperhidrosis: Challenges And Solutions

Figures & data

Table 1 Summary Of Palmar Hyperhidrosis Treatments

Type	Mechanism Of Action	Clinical Recommendation	Side Effects	Level Of Evidence*	Ref
Topical therapies
10–35% AC in water, alcohol, SA gel, or thermophobic foam	Blockade of distal sweat gland ducts	First-line option in most cases of PH, regardless of severity	Local skin irritation	L2/3	^Citation5^–^Citation14
Iontophoresis, TWI ± supplemented media or dry-type	Unclear	First- or second-line medical device therapy, often after AC failure	Local discomfort and/or irritation	L2/3	^Citation5^–^Citation7,Citation9,Citation17,Citation18,Citation20^–^Citation33
Intradermal BoNT injections	Blocking pre-synaptic release of acetylcholine	First- or second-line treatment	Injection-site pain, discomfort, and/or irritation, reversible hand weakness, compensatory sweating	L2	^Citation5^–^Citation7,Citation9,Citation37^–^Citation49
Systemic therapy
Oral anticholinergics (alone or as adjuvant)	Competitive blocking sweat gland activation by acetylcholine	Next line treatment if topical modalities are ineffective or contraindicated	Systemic anticholinergic activity (oral/ocular dryness, vision changes, constipation, urinary hesitancy, closed-angle glaucoma)	L2	^Citation5^–^Citation8,Citation10,Citation15,Citation50^–^Citation68
Surgical therapy
ETS	Disrupting sympathetic nerve signal outflow to sweat glands	Indicated if non-surgical treatments fail	Compensatory/gustatory/phantom sweating, subcutaneous emphysema, pneumothorax, Horner’s syndrome, bradycardia	L2	^Citation5^–^Citation8,Citation10,Citation69^–^Citation78
New/Emerging therapies
Topical anticholinergics	Competitive inhibition of acetylcholine	Despite promising initial results, topical formulations for palmar use largely remain under investigation	Systemic anticholinergic effects, contact sensitization	L2	^Citation10,Citation15,Citation20,Citation80^–^Citation89
BoNT-A cream/gel	Blocking pre-synaptic release of acetylcholine	BoNT-A in the form of cream/gel currently applies only to the axillae	Further research is needed to evaluate safety and tolerability	L2	^Citation90,Citation91
High-frequency ultrasound	Noninvasive stellate ganglion blockade	Adjuvant or alternative option for refractory cases	Surgical risks can be avoided, although further research is needed to evaluate safety and tolerability	L5	^Citation92

Notes: *L1 = Systematic review of randomized trials or n-of-1 trials; L2 = Randomized trial or observational study with dramatic effect; L3 = Non-randomized controlled cohort ⁄ follow-up study; L4 = Case-series, case-control studies or historically controlled studies; L5 = Mechanism-based reasoning.¹⁰ Information about “The Oxford 2011 Levels of Evidence” are available at http://www.cebm.net/index.aspx?o=5653.

Abbreviations: AC, aluminum chloride hexahydrate; BoNT, botulinum neurotoxin; ETS, endoscopic thoracic sympathectomy; L, level; PH, palmar hyperhidrosis; Ref, references; SA, salicylic acid; TWI, tap water iontophoresis.

Figure 1 Schematic diagram showing a treatment algorithm for PH.

Abbreviations: HDSS, Hyperhidrosis Disease Severity Scale; BoNT, botulinum neurotoxin; AC, aluminum chloride hexahydrate; ETS, endoscopic thoracic sympathectomy.

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