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	5–14
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	5–7,9,17,18,20–33
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	5–7,9,37–49
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	5–8,10,15,50–68
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	5–8,10,69–78
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	10,15,20,80–89
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	90,91
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	92

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.