Hyperhidrosis

This treatment guideline is aimed to provide primary care clinicians with guidance on how to manage hyperhidrosis in adults.

Hyperhidrosis can be classified by location (focal or generalised) and by the presence of an underlying cause (primary or secondary).

  • Primary focal hyperhidrosis has no underlying cause. It is also known as primary idiopathic, primary localised, or focal hyperhidrosis. It most commonly affects the axillae, and may also involve the palms, soles of the feet, face, scalp, and groin.
  • Secondary focal hyperhidrosis involves specific areas of the body, caused by an underlying condition.
  • Generalised hyperhidrosis affects the entire skin surface area, and it usually has an underlying cause.
  • The Hyperhidrosis Disease Severity Scale (HDSS) is commonly used to assess condition severity based on the impact of sweating on daily activities.

Initial assessment

Determine if hyperhidrosis is caused by an underlying condition

Determine if hyperhidrosis is primary or secondary caused by an underlying condition as below:

  • Pregnancy
  • Anxiety
  • Drug history (anticholinesterases, antidepressants, propranolol)
  • Irregular periods (menopause)
  • Palpitations and heat intolerance (thyrotoxicosis)
  • Diabetes (autonomic neuropathy, hypoglycaemia)
  • Night sweats (haematological malignancy or tuberculosis)
  • Weight loss (malignancy)
  • Substance misuse (alcohol withdrawal, amphetamines)

Assessment of primary hyperhidrosis

  • Assess site e.g. axillary, palmo-plantar – hyperhidrosis
  • Assess impact on daily life using the validated Hyperhidrosis Disease Severity Scale (HDSS Score):
    • Score 1: My sweating is never noticeable and never interferes with my daily activities
    • Score 2: My sweating is tolerable but sometimes interferes with my daily activities
    • Score 3: My sweating is barely tolerable and frequently interferes with my daily activities
    • Score 4: My sweating is intolerable and always interferes with my daily activities
  • 1 to 2 points is regarded as mild to moderate, 3 to 4 points is moderate to severe.

Secondary hyperhidrosis

If secondary hyperhidrosis, treat the underlying cause.

Lifestyle advice for primary hyperhidrosis

  • Avoid known triggers (e.g. crowded rooms, caffeine, spicy foods etc.) where possible.
  • For axillary hyperhidrosis: avoid tight clothing and manmade fabrics, wear white clothing to minimise signs of sweating, consider armpit shields.
  • For plantar hyperhidrosis: moisture-wicking socks, changing socks twice daily, absorbent soles, absorbent foot powder e.g., Zeasorb® dusting powder available over-the-counter (OTC), avoid occlusive footwear, alternate pairs of shoes daily to allow them to dry out.

Treatment of Primary Focal Hyperhidrosis

Treatment option 1

Topical strong antiperspirants (20% to 5% aluminium salts) e.g. Driclor®, Anhydrol Forte®.

  • Patients should be asked to purchase OTC. Refer to NHS SWL Self Care Guidance for Clinicians.
  • Instructions for use: use at night on bone dry skin in a cool environment and wash off in the morning. For the first week it should be applied for 3 to 5 consecutive nights, then once or twice a week.
  • If there is local irritation, manage with emollients, reduction in frequency of application or apply hydrocortisone 1% cream the morning after the treatment if necessary (also purchased OTC).

Review

Review after 6 weeks:

  • If successful after 6 weeks (reduction in HDSS from 3 or 4 to 1 or 2), continue and review medications regularly
  • If not successful after 6 weeks of treatment, consider treatment option 2.

Treatment option 2

Oral anticholinergics: Propantheline (licensed for generalised hyperhidrosis) 15mg three times a day, one hour before each meal, and 30mg at bedtime. May be increased up to 120mg per day.

  • Anticholinergics should be taken one hour before the application of aluminium chloride, preventing sweating and irritation.
  • Counsel patients as regards possible side effects e.g., constipation, blurred vision, dry mouth, photophobia, dry skin, and urinary retention.
  • Contraindications include significant bladder outflow obstruction, and gastro-intestinal obstruction.

Review

Review treatment option 2 after 1 month:

  • If successful after 1 month (reduction in HDSS from 3 or 4 to 1 or 2), continue and review medications regularly.
  • If not successful after 1 month or treatment limiting side effects:
    • HDSS 1 to 2: stop treatment and manage with lifestyle advice and OTC topical treatments.
    • HDSS 3 to 4: refer to secondary care for consideration of other medical treatments if unresponsive to the above treatments.

Treatment option 3

For severe primary axillary hyperhidrosis in adults, glycopyrronium bromide (Axhidrox®) cream can be used as an option in adults, if lifestyle advice, topical aluminium-based antiperspirants and oral antimuscarinics in line with NICE TA1175: Glycopyrronium bromide cream for treating severe primary axillary hyperhidrosis:

  • have not controlled underarm sweating, or
  • are contraindicated or not tolerated.

Glycopyrronium bromide cream to be recommended by a specialist (through Advice and Guidance) for prescribing in primary care (Amber 1 on SWL formulary).  Patient review by the GP is recommended after the first 4 weeks of treatment to determine benefit and if reduction of application to twice a week is appropriate (using the HDSS score).

  • During the first 4 weeks of treatment, Axhidrox® is applied to each armpit evenly, once a day, preferably in the evening. Patient should be advised to refer to the product patient information leaflet for guidance on how to apply the cream.  This includes applying using the pump’s cap rather than the fingers, dispensing exactly two pump actuations per armpit, washing both the pump cap and hands with soap and water immediately after application, and avoiding eye, nose, or mouth contact with the drug to prevent systemic effects like blurred vision and temporary dilation of the pupil.
  • From the 5th week on, the frequency of application of Axhidrox® may be reduced to twice a week, depending on the reduction of axillary sweating.
  • Continuous treatment of primary axillary hyperhidrosis with Axhidrox® is required to maintain the effect.
  • Seek specialist advice (through Advice and Guidance or via specialist referral). if Axhidrox® has not controlled or reduced underarm sweating, or poorly tolerated or where the diagnosis or further management is uncertain.

Treatment option 4 (access to specialist treatments)

Treatment options depend on symptom severity, body region affected, potential adverse effects and complications, local availability, and the person’s wishes.

Treatment of Primary Generalised Hyperhidrosis

Oral anticholinergics: Propantheline (licensed for generalised hyperhidrosis) 15mg three times a day, one hour before each meal, and 30mg at bedtime. May be increased up to 120mg per day.

  • Anti-cholinergics should be taken one hour before the application of aluminium chloride, preventing sweating and irritation.
  • Counsel patients as regards possible side effects e.g., constipation, blurred vision, dry mouth, photophobia, dry skin, and urinary retention.
  • Contraindications include significant bladder outflow obstruction, and gastro-intestinal obstruction.

Review

Review after 1 month:

  • If successful after 1 month (reduction in HDSS from 3 or 4 to 1 or 2), continue and review medications regularly
  • If not successful after 1 month or treatment limiting side effects:
    • HDSS 1 to 2: stop treatment and manage with lifestyle advice and OTC topical treatments.
    • HDSS 3 to 4: refer to secondary care for consideration of other medical treatments if unresponsive to the above treatments.

To the best of our knowledge, the information provided in this guideline is accurate and reliable as available at the time of issue. Always consult the Summary of Product Characteristics for full prescribing information.

References

(Note: As of September 2026, not all resources have been updated to include the use of glycopyrronium bromide cream as per NICE TA1175)

Document History

Treatment guidelines for hyperhidrosis V2 approved by SWL Integrated Medicines Optimisation Committee (IMOC) October 2026.