What are the recommended first-line treatments for primary hyperhidrosis in adults?

First-line treatments for primary hyperhidrosis in adults typically start with topical antiperspirants containing aluminium chloride hexahydrate. These are applied to affected areas such as the underarms, palms, or soles to reduce sweating by blocking sweat ducts.

For patients who do not respond adequately to topical treatments, oral anticholinergic medications may be considered, although their use is limited by side effects. These systemic agents reduce sweat production by inhibiting acetylcholine-mediated stimulation of sweat glands.

In addition, iontophoresis is a non-invasive option often recommended for palmar and plantar hyperhidrosis, involving the use of electrical currents to reduce sweating.

Recent literature also highlights the role of botulinum toxin injections as an effective treatment for focal hyperhidrosis, particularly in the axillae, palms, and soles, though this is generally considered after failure of first-line topical and oral therapies.

Overall, the UK clinical guidelines emphasize starting with topical aluminium chloride, progressing to oral anticholinergics or iontophoresis if needed, while recent studies (Jacob, 2018) support botulinum toxin as a valuable subsequent option for refractory cases.

Thus, the integrated approach for first-line management in adults with primary hyperhidrosis is:

• Topical aluminium chloride hexahydrate antiperspirants
• Oral anticholinergic agents if topical treatment is insufficient
• Iontophoresis for palmar/plantar hyperhidrosis

with botulinum toxin reserved for treatment-resistant cases (Jacob, 2018) ¹.