Managing hyperhidrosis in general practice

Dr William Crane — managing hyperhidrosis in general practice

Dermatologist; founder of Carer Dermatology in Melbourne; advanced training in complex medical, laser, and aesthetic dermatology; formerly Australia’s largest laser dermatology centre in Brisbane; board member, Australasian Society of Cosmetic and Procedural Dermatologists; research interest including acne and acne scarring. Otter/intro name Crane — we keep that byline and do not invent an alternate surname.

Host

Healthed seminar host (speaker intro; main talk is Dr Crane).

Why this matters — underdiagnosis

Hyperhidrosis is common and often missed. Dr Crane estimates at least ~5% of the population — more than a million Australians — likely live with it. Many patients assume excessive sweating is “just how they are,” never raise it, and learn to cope from the teenage years: spare shirts, frequent laundry, avoiding certain colours, dating anxiety, and difficulty holding pens.

Quality-of-life impact can rival other chronic conditions (rheumatoid arthritis, MS, end-stage renal disease have been used as research comparators). It often appears as a tacked-on end-of-appointment comment. Giving patients permission to book a dedicated review, and walking a clear assessment and treatment ladder, picks up both primary and secondary cases — and offers more than another pharmacy antiperspirant.

Eccrine vs apocrine / bromhidrosis

Primary focal hyperhidrosis is mainly an eccrine problem. Eccrine glands are densest in the axillae, palms, soles, and forehead — the classic focal sites. They open onto the skin surface and produce dilute, watery sweat.

Apocrine glands feed into hair follicles and produce a more oily sweat that can become malodorous when bacteria act on it — that odour complaint is bromhidrosis, a related but different clinical problem from volume hyperhidrosis.

Treatment targets — plug vs tap

All current options are temporary and need maintenance. Different drugs hit different parts of the gland:

• Aluminum salts — temporary plug at the duct opening (efferent duct).
• Anticholinergics (topical glycopyrronium / Axhidrox; oral agents) — block muscarinic receptors in the secretory coil (“turn off the tap”).
• Botulinum toxin — upstream block of acetylcholine release onto the coil.

A useful patient analogy: untreated, the bath tap is on and the plug is out. Aluminum chloride puts the plug in — sweat is still made, so improvement can be only partial. Anticholinergics try to turn the tap down so people sweat a more normal amount.

Primary focal criteria & the sleep question

The single highest-yield question: Does sweating wake you at night / continue in sleep? Primary focal hyperhidrosis typically stops in sleep. Night sweats or drenching nocturnal sweating point away from primary focal disease toward secondary causes or vasomotor symptoms.

Diagnostic criteria used to access on-label / PBS pathways (as framed in the talk):

• Bilateral (usually relatively symmetrical)
• At least one episode a week
• Onset usually before age 25 (not absolute)
• Often family history; no systemic features
• Sweating that ceases during sleep

Secondary causes & red flags

Highest yield among secondary drivers: medications — especially SSRIs and SNRIs, which may start or worsen sweating. Discuss staying on the drug for its benefit vs switching vs adding a hyperhidrosis treatment.

Other secondary / contributing contexts mentioned: thyroid dysfunction; tamoxifen; multimorbidity in older adults with new-onset sweating. Do not over-investigate everyone with a full rare-disease panel — thyroid and a structured medication review catch most actionable finds. Rare entities (e.g. mast-cell disorders, uncommon tumours) turn up occasionally.

Perimenopause / menopause flushing is often confused with hyperhidrosis. Vasomotor flushing tends to be generalised upper-body, and night sweats are typical. Primary focal hyperhidrosis should cease in sleep — that distinction matters for pathway choice.

HDSS and PBS severity

For PBS access, document moderate or severe disease using a simple Hyperhidrosis Disease Severity Scale (HDSS)–style framing:

• Moderate — barely tolerable; frequently interferes with daily activities
• Severe — intolerable; always interferes with daily activities

Academic QoL instruments exist but are rarely used in day-to-day practice. Document tolerability and activity impact if you will prescribe PBS options — that retrospective justification matters.

Aluminum chloride 20% night protocol

First-line topical for many: 20% aluminum chloride, used correctly. Many patients think they have “tried prescription strength” but used pharmacy antiperspirant like a fragrance.

Counselling checklist (also part of criteria before stepping up):

• What product? How used? How long?
• Apply at night on clean, dry skin (moisture + aluminum → hydrochloric acid → irritant dermatitis)
• Wash off in the morning; daytime fragrance / normal antiperspirant OK
• Use consistently for about a month, then reduce frequency as tolerated

Main adverse effects: irritation, burning, stinging. Night-only application is the common fix when people have been using it by day.

Axhidrox (glycopyrronium) — PBS ladder

Axhidrox is topical glycopyrronium, available on PBS for physicians in Australia (speaker started using it from early in the year of availability). Previously, compounded glycopyrrolate solutions were costly and inconsistent ($100–$300 heard).

Rough PBS framing from the lecture (confirm current PBS criteria before prescribing):

• Moderate or severe primary focal (axillary) hyperhidrosis
• Failed a proper aluminum chloride course or intolerant
• Not if the patient has already received other PBS hyperhidrosis treatment — notably PBS Botox (one pathway or the other in the criteria discussed)

How to use Axhidrox (as counselled)

• Pump onto the cap applicator — do not get product on fingers then into eyes/nose; wash hands if contact occurs
• Generally night, clean dry underarm skin; can use with normal deodorant
• Daily for about 1 month, then usually 2–4 times per week to maintain
• Expect roughly ~70% sweat reduction / near-normalisation of gravimetric sweat volume by ~4 weeks in phase-3 style data described (adults with primary axillary disease, HDSS moderate/severe)
• QoL / HDSS improved substantially in the studies cited (e.g. HDSS improving by about two points — threes/fours toward zeros/ones)
• First month cost mentioned around $25 PBS co-pay style; stretching frequency makes scripts last longer
• AEs mostly mild: underarm dryness (less moisture); if applied to hands, hands can feel “slippery” / loss of tactile sweat sensation

Botox, miraDry, avoid rushing sympathectomy

Botulinum toxin: works well; expect 2–3 treatments per year with a tail-off; can be painful and is an ongoing expense. Criteria similar to topical PBS path (failed/intolerant aluminum chloride; age framing over 12 in the criteria slide discussed). Patients often prefer a topical option if eligible.

miraDry (microwave thermolysis): a device that suction-cooks axillary sweat glands — a semi-permanent non-surgical option available in some dermatology clinics (speaker referenced Newstead clinic experience).

Sympathectomy: avoid jumping there early. Speaker sees many poor responders after surgery and prefers exhausting topicals, anticholinergics (off-label oral when appropriate), and microthermolysis before surgical referral — acknowledging surgeons may report good selected outcomes.

Palms and soles

Palmoplantar disease hits young people hard (pens, exam papers). There is no approved on-label PBS topical for palmar hyperhidrosis in the framing given.

• Iontophoresis — home device DermaDry (speaker: often on special around Black Friday); still used a lot
• Botox to palms — painful, expensive, limited longevity satisfaction
• Oral oxybutynin (and similar) — can be life-changing at small doses, but watch brain fog and dry mouth in young people / school performance; parents worry about long-term meds
• Axhidrox off-label private for palms — same regime, patient aware it is off-label and private (~$150 mark heard)

When to refer — and a worked axillary case

Dr Crane now often waits until patients have tried Axhidrox (when appropriate) before or while waiting for dermatology — waitlists are long and people drop off; an active topical phase is useful. Dermatologists can send satisfied patients back on a topical regime rather than indefinite Botox.

Refer to the right specialist if secondary disease needs physician input — dermatology is wrong for unexplained night sweats with red flags.

Classic axillary case (from the talk)

22-year-old university / work student with spare shirts — HDSS intolerable / interfering. Visit 1: start aluminum chloride with written night protocol; document severity; review ~4–8 weeks. Visit 2: intolerant or inadequate response, HDSS ≥3 → eligible for Axhidrox: applicator technique, daily × 1 month, then titrate down.

Contrast: someone who has not yet tried aluminum chloride properly — finish that step first. Someone with multiple red flags — investigate / refer appropriately, not Axhidrox-first.

Take-home messages for clinic

1. Hyperhidrosis is underdiagnosed (~5%); ask — patients often will not lead with it.
2. Eccrine volume sweating ≠ apocrine bromhidrosis; treatments target plug, coil anticholinergic, or Botox.
3. Key question: does it stop in sleep? If not, think secondary / vasomotor.
4. Highest-yield secondary: SSRIs/SNRIs and other meds; thyroid / tamoxifen / menopause flushing patterns.
5. Document HDSS moderate/severe before PBS pathways.
6. Aluminum chloride 20% at night on dry skin, wash morning — fail or intolerant before Axhidrox.
7. Axhidrox: applicator hygiene; daily 1 month then 2–4×/week; ~70% reduction; not if already on PBS Botox.
8. Botox 2–3×/year; consider miraDry; do not rush sympathectomy.
9. Palms/soles: DermaDry iontophoresis; oral oxybutynin caveats; Axhidrox off-label private.
10. Refer after a proper topical trial when criteria fit; match referral to primary vs secondary cause.

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