Mild: A score of 1 or 2 indicates mild or moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box.

Self-care management strategies  

Primary axillary hyperhidrosis: 

• Commercial antiperspirant rather than deodorant. 
• Use emollient washes, rather than soap-based products 
• Avoid tight clothing and man-made fabrics 

Primary Plantar Hyperhidrosis: 

• Alternate footwear 
• Moisture wicking-socks, change twice daily 
• Avoid occlusive footwear such as boots-encourage leather shoes 

Primary focal hyperhidrosis: 

• 20% aluminium chloride hexahydrate over the counter preparations such as roll-on antiperspirants and spray.  
• Apply at night just before sleep to skin of the axillae, feet, or hands every 1–2 days as tolerated, until symptoms improve, then use as required. Wash off in the morning. 
• For craniofacial hyperhidrosis, consider antiperspirant wipes (aluminium chloride) for application to the face (off-label use). 

If skin irritation occurs with aluminium salt preparations, prescribe hydrocortisone 1% cream to be applied once daily for up to two weeks. Also advise soap substitute and to reduce frequency of application until symptoms resolve. 

Moderate: A score of 2 or 3 indicates moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box. 

Oral and topical therapy 

• Higher strength aluminium salts (up to 50%). 
• Topical glutaraldehyde or formaldehyde may be used. 
• Topical glycopyrrolate may be useful for primary craniofacial hyperhidrosis (off-label indication) although is availability is usually within a secondary care setting. 
• Oral anti-muscarinics such as oxybutynin and glycopyrronium bromide. Beware anti-muscarinic side effects.  

Oral antimuscarinics decrease sweat secretion.  

• Oxybutynin (standard release): 5mg OD initially, then increase to twice daily. Unlicenced indication.  
• Propantheline: 15mg TDS one hour before meals. Licenced. Dose could be titrated up to maximum of 120mg/day. 

Patients should be counselled with regards to anti-muscarinic side effects. 

 Iontophoresis therapy  

• Recommended for palms and soles. Axillary treatment is impractical. If unsuccessful, glycopyrronium bromide (an anti-muscarinic agent) may be added to the water. Long term maintenance required.  
• Iontophoresis machines can be rented/purchased and information regarding this is available on the international hyperhidrosis society website (link below) 

Severe: A score of 3 or 4 indicates severe hyperhidrosis.  See hyperhidrosis disease severity scale in clinical resources box. 

Botulinum A Toxin: 

• Largely used for axillary hyperhidrosis 
• Can be used for palms, soles, craniofacial hyperhidrosis but treatment is painful in these areas, limiting use. Effects last 6-9 months. 

Surgery  

• Localized sweat gland resection may be carried out for small areas of axillary hyperhidrosis.  
• Endoscopic thoracic sympathectomy (ETS) should only be considered when all other options are ineffective or not tolerated.  
• Complications include compensatory hyperhidrosis elsewhere on the body (very common), pneumothorax (common, gustatory sweating (common), atelectasis, significant bleeding.  

Please note surgical approaches are rarely utilised due to the potential risks involved. 

Mild: A score of 1 or 2 indicates mild or moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box. 

Manage in primary care using self-care measures and topical advice. 

See NICE guidance below: 

Refer to the dermatologist to consider specialist management if self-care and topical drug treatments are ineffective/not tolerated. Individual funding requests may be required for certain treatments e.g. Botulinum A Toxin and local availability varies.  

Moderate: A score of 2 or 3 indicates moderate hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box. 

Manage in primary care with oral and topical therapies.  

Refer to secondary care or consultant-led community service for iontophoresis/ Botulinum toxin (if commissioned locally). 

Severe: A score of 3 or 4 indicates severe hyperhidrosis. See hyperhidrosis disease severity scale in clinical resources box.

Refer to secondary care or consultant-led community service for iontophoresis and Botox (if commissioned). 

Availability of surgical intervention varies locally and may require individual funding requests. 

Hyperhidrosis Disease Severity Scale (HDSS) diagnostic tool  

International Hyperhidrosis Society (sweathelp.org)

Dermatology Quality of Life Index (DLQI) 

NICE CKS Summary- Hyperhidrosis 

NICE Evidence Summary: Oxybutynin for hyperhidrosis 

• In the context of generalised hyperhidrosis, consider screening for underlying medical causes  
• Drug-induced causes of generalised hyperhidrosis include beta blockers, SSRIs, tricyclic antidepressants and opiates. 
• After a successful trial of iontophoresis, patients may be advised to purchase their own device for long-term maintenance. 

1. Hyperhidrosis BAD patient information leaflet 

2. NHS information leaflet: Excessive sweating (hyperhidrosis) 

3. Hyperhidrosis UK Support Group leaflet 

4. NHS Inform- Hyperhidrosis 

Epidermal/Appendageal 

ICD11 code - EE00