Nonsurgical management of hyperhidrosis.

HH is a chronic disease that can have a significant negative impact on a patient's quality of life. Primarily involving the axillae, palms, soles, and face, patients who have primary focal HH seek medical advice often long after they have been living with functional and psychosocial disability for some time. For every affected area of HH and at every stage of disease severity, conservative measures should be exhausted before progressing to surgical options. Treatment should be particular to each individual patient and chosen based on disease severity, expectations for improvement, and disease location. Generally, the most conservative options with the fewest adverse effects are attempted first. These include topical therapy (primarily AlCl3-6H2O) and iontophoresis. Patients who are less likely to respond to these measures are those living with severe disease (HDSS score of three or four). A minimally invasive procedure, intradermal BTX injections have been shown to improve disease significantly in these patients. Serving as an intermediate between conservative therapy and invasive surgery, BTX has revolutionized the treatment of focal HH. In many large controlled studies, it has been proved to be safe, efficacious, quick acting, and long lasting. Although BTX-A is most commonly used and studied, preliminary studies of BTX-B have demonstrated its potential to ameliorate focal HH significantly. Oral medications such as glycopyrrolate can be tried alone at any point in treatment, or as a useful adjunct, but side effects are common and caution should be taken with high-risk patients. For all forms of HH, the desired outcome for treatment should be qualitative and quantitative and it is critical for physicians to assess the patient's improvement periodically and adjust therapy, based on these therapeutic landmarks.