Primary focal hyperhidrosis involves specific areas of the body but has no identifiable underlying cause.

Advice

Self-care management strategies include:

• Avoidance of any identified triggers where possible
• Using an antiperspirant (not just a deodorant)
• Moisture-wicking clothes/footwear that are loose fitting
• Management of underlying or associated anxiety (N.B. drug treatments such as selective serotonin inhibitors may worsen symptoms)
• Some patients may wish to consider tap-water iontophoresis (particularly for palmar or plantar hyperhidrosis). These machines are not provided by the NHS in Devon but are available to rent or purchase. Advice is available from the British Association of Dermatologists and Hyperhidrosis UK.

Additional advice and support for patients is available from the British Association of Dermatologists, Hyperhidrosis UK and the NHS information leaflet for excessive sweating (hyperhidrosis).

Topical treatment

Where standard antiperspirant products are ineffective, consider advising the use of an aluminium chloride hexahydrate 20% roll-on antiperspirant or spray. These are readily available over the counter (OTC) from pharmacies and can be used alongside other self-care management strategies.

Aluminium chloride hexahydrate 20% roll-on applicator

• Apply once daily at night to dry skin, wash off the following morning, reduce frequency as condition improves.
• This product is available to purchase OTC. In line with guidance from NHS England (see above), it should not be routinely prescribed in primary care for patients with mild to moderate hyperhidrosis.
• Refer to 13.12 Antiperspirants for further information.

Review after 6 weeks. If response is inadequate or treatment is not tolerated, oral treatment with systemic anticholinergics can be considered.

Oral treatment

Consider treatment with an oral systemic anticholinergic where there is an inadequate response to at least 6 weeks of treatment with a topical aluminium antiperspirant and self-care management strategies. Where tolerated, topical aluminium products can be continued alongside oral treatment.

Although it is an off-label use, specialists advise that for patients with hyperhidrosis, oxybutynin is considered ahead of the licensed alternative (propantheline bromide) owing to greater evidence of efficacy and lower cost

Oxybutynin hydrochloride (off-label)

• Immediate release: Initially 2.5mg once daily, adjusted according to response and tolerability; maximum 10mg daily given in two to four divided doses.
• Modified release: Where immediate release products are not tolerated. Initially 5mg once daily, increased if required to a maximum dose of 10mg once daily.
• Refer to 7.4.2 Drugs for urinary frequency, enuresis, and incontinence for further information

OR

Propantheline bromide

• 15mg three times daily at least 1 hour before meals and 30mg at night, maximum 120mg daily.
• Refer to 1.2 Antispasmodics and other drugs altering gut motility for further information

Review after 6 weeks. If response is inadequate after at least 6 weeks at the maximum tolerated dose of oxybutynin or propantheline, or treatment cannot be tolerated, consider making an Advice and Guidance request to Dermatology.

Specialist referral

Refer to Hyperhidrosis Clinical Referral Guidelines:

• Western Locality
• South Devon and Torbay

Secondary hyperhidrosis occurs due to an underlying condition or as a side effect of medication. Cases are usually generalised, affecting the entire skin surface. Whilst secondary focal hyperhidrosis can occur, cases are rare.

Initial management should focus on the identification and management of underlying causes (See Hyperhidrosis clinical referral guidelines: Western Locality / South Devon and Torbay).

For patients with moderate to severe hyperhidrosis (HDSS score of 3 or 4) where symptoms persist despite the management of underlying causes, consider oral treatment with a systemic anticholinergic drug.

Oral treatment

Although it is an off-label use, specialists advise the use of oxybutynin rather than the licensed product propantheline bromide, owing to greater evidence of efficacy and lower cost.

Oxybutynin hydrochloride (off-label)

• Immediate release: Initially 2.5mg once daily, adjusted according to response and tolerability; maximum 10mg daily given in two to four divided doses.
• Modified release: Where immediate release products are not tolerated. Initially 5mg once daily, increased if required to a maximum dose of 10mg once daily.
• Refer to 7.4.2 Drugs for urinary frequency, enuresis, and incontinence for further information.

OR

Propantheline bromide

• 15mg three times a day at least 1 hour before meals and 30mg at night, maximum 120mg daily.
• Refer to 1.2 Antispasmodics and other drugs altering gut motility for further information.

Review after 6 weeks. Where response is inadequate after at least 6 weeks at the maximum tolerated dose, or treatment cannot be tolerated, consider making an Advice and Guidance request to Dermatology.

Specialist referral

Refer to Hyperhidrosis Clinical Referral Guidelines:

• Western Locality
• South Devon and Torbay