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Hyperhidrosis

“Doc, I’m so embarrassed. My sweating is out of control! I change my shirt twice a day, my shoes get ruined and I can’t write without making the paper wet…”

Hyperhidrosis is a chronic condition involving overreactive sweat glands. True prevalence is unknown because of underreporting and underdiagnosis. It can severely affect patients’ quality of life, relationships and work. This article is drawn from a BJGP Clinical Practice piece on the topic (BJGP 2024;74:236). 

This article was updated in August 2026.

Causes and categories 

In 2024, a BJGP article suggested the following way for thinking about hyperhidrosis (BJGP 2024;74:236): 

Assessment and investigation

The BJGP suggested (BJGP 2024;74:236): 

  • History should include:
    • Distribution of sweating, onset, timings and triggers.
    • Psychosocial impact.
    • Drug history, family history and comorbidities.
    • Associated symptoms, e.g. weight loss, palpitations (if there are night sweats, be particularly cautious about excluding infection and malignancy).
  • Examination should look for:
    • Signs of any underlying condition.
    • Signs of any complications such as intertrigo or bacterial skin infection.
  • If a specific secondary cause or causes are suspected, tailor investigations to these and refer as appropriate.
  • If symptoms and signs are non-specific, the BJGP article suggests these investigations:
    • FBC, U&Es, CRP, LFTs, TFTs, HbA1c.
    • Chest X-ray.

Management

In 2024, the BJGP article suggested the following management strategies; we have also added information from the 2026 NICE TA on glycopyrronium bromide cream (BJGP 2024;74:236, NICE TA1175, 2026): 

The BJGP doesn’t specify whether these management strategies are for primary or secondary hyperhidrosis, and we take this to mean that they can be used in either. The important thing to remember is that the treatment of secondary hyperhidrosis also involves addressing the underlying cause where possible!

Simple patient-initiated measures
  • Loose clothing made from natural fibres.
  • Leather shoes, open design if possible.
  • Moisture-wicking socks and insoles.
  • Over-the-counter antiperspirants.
  • Underarm pads.

Prescribable in primary care

 
  • Topical aluminium chloride antiperspirants (prescribable as 20% solution, e.g. Anhydrol forte, Driclor).
    • Can be used on either a PRN or regular basis.
    • Up to 80% effective in mild to moderate hyperhidrosis.
    • Apply on clean, dry skin at night and wash off in the morning.
    • Can cause skin irritation: treat with mild topical steroids if needed.
    • The BJGP piece recommends a 6w trial of topical aluminium chloride antiperspirants before moving on to other measures.
  • Oral antimuscarinics
    • Side-effects include dry eyes (causing blurred vision), dry mouth, constipation and urinary retention. The BNF reminds us to be cautious in prescribing to those who may be at risk of antimuscarinic side-effects, including angle-closure glaucoma, GI obstruction and urinary retention (BNF NICE – propantheline bromide, accessed August 2026).
    • The only licensed preparation is propantheline bromide (15mg three times a day, then 30mg before bed OR 40mg once daily, increasing to 40mg three times a day). Needs to be taken an hour before food.
    • Oxybutynin is an unlicensed alternative (2.5mg once daily, increasing gradually to 5mg twice daily if tolerated). NICE endorsed this off-licence use in 2017 (NICE 2017, ES10).
  • Glycopyrronium bromide cream (NICE TA1175, 2026): 
    • For severe primary axillary hyperhidrosis in adults, PROVIDED lifestyle advice, topical aluminium chloride antiperspirants and oral antimuscarinics have be not been effective/are contraindicated/not tolerated. NB: armpits only! More information below. 
Secondary care (dermatology)
  • Other oral treatments, including beta-blockers, calcium channel blockers and oral glycopyrronium. 
  • Iontophoresis (see below). 
  • Botox.
  • Surgical or laser removal of sweat glands.
  • Endoscopic thoracic sympathectomy: reserved for extreme cases. Involves cutting the sympathetic chain as it passes through the pleural cavity. Complications include pneumothorax, pneumonia, pain, bleeding and compensatory sweating.
  • Emerging treatments not yet available in the UK include targeted alkali thermolysis patches.

What place for iontophoresis?

Iontophoresis involves passing an electric current through an ion-rich medium in which the affected part of the body is placed (or via pads for the axilla). 

The BJGP review suggested that iontophoresis was available through secondary care, but the NICE TA says it is not available on the NHS. That means patients wishing to try this must buy/rent the devices themselves (they cost several hundred pounds to buy) (BJGP 2024;74:236, NICE TA1175, 2026).

Glycopyrronium bromide cream

The SPC tells us (EMC – product 101983):

  • It is to be used in the armpits only, and is only licensed for adults (≥18y).
  • Available as Anhidrox pump-pack 2.2mg/pump. Recommended dose is 2 pumps per armpit once daily for 4 weeks, then reduce to twice weekly, depending on amount of sweating. Each tube should last 1 month with daily use to both armpits. It costs £69.50 for a tube (NICE TA1175, 2026).
  • IMPORTANT! The cream is pumped out onto the lid, NOT onto the fingers, and is applied to the armpits from the lid (to prevent topical absorption from fingers, or subsequent spread to eyes, nose and mouth). The effect lapses if you stop using it. 
  • Because it is an antimuscarinic, there are warnings about use in those for whom this might be an issue, including those with (EMC – product 101983):
    • History of/at risk of urinary retention (e.g. severe prostatic hyperplasia).
    • Coronary artery disease, CCF, arrhythmias and hypertension; however, significant cardiac antimuscarinic side-effects such as tachycardia are uncommon (1 in 100 to ≥1 in 1000) 
  • The commonest side-effect is a dry mouth (affecting more than 1 in 10).

Evidence on effectiveness and cost-effectiveness 

The NICE TA tells us that (NICE TA1175, 2026):

  • The evidence for effectiveness presented to NICE was two phase 3 RCT comparing the glycopyrronium cream with placebo. 
  • There were no clinical trials comparing the cream with oral antimuscarinics or botox, but indirect studies suggest the cream may be LESS effective than these treatments. However, it is cheaper than botox and some of the other secondary care options, and avoids the systemic side-effects of oral antimuscarinics. 

Hyperhidrosis

  • Can be primary or secondary, and localised or generalised. Generalised hyperhidrosis is usually secondary.
  • An important goal of assessment is to exclude serious underlying causes; this should usually include examination, bloods and a chest X-ray.
  • Initial management includes simple lifestyle measures and a 6w trial of topical aluminium chloride antiperspirant. 
    • If these fail, we can consider an oral antimuscarinic. 
    • If this is ineffective, glycopyrronium bromide cream can be used for axillary hyperhidrosis. 
    • If these are ineffective, refer to dermatology. 

Useful resources:
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