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A Comprehensive Approach to the Recognition, Diagnosis, and Severity-Based Treatment of Focal Hyperhidrosis: Recommendations of the Canadian Hyperhidrosis Advisory Committee


  • Disclaimer: Adherence to the recommendations in this article will not ensure successful treatment in every situation. Furthermore, these recommendations should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. Final judgment of any specific therapy should be made by the physician and the patient considering all the circumstances presented by the individual patient. All doses and recommendations pertaining to botulinum toxin A (BTX-A) apply specifically to BOTOX (Allergan Inc., Irvine, CA) unless otherwise noted.

Address correspondence and reprint requests to: Nowell Solish, MD, FRCPC, Dermatologist, New Women's College Hospital, 76 Grenville Street, Room 841, Toronto, Ontario M5S 1B2, Canada, or e-mail:


BACKGROUND Hyperhidrosis can have profound effects on a patient's quality of life. Current treatment guidelines ignore disease severity.

OBJECTIVE The objective was to establish clinical guidelines for the recognition, diagnosis, and treatment of primary focal hyperhidrosis.

METHODS AND MATERIALS A working group of eight nationally recognized experts was convened to develop the consensus statement using an evidence-based approach.

RECOMMENDATIONS An algorithm was designed to consider both disease severity and location. The Hyperhidrosis Disease Severity Scale (HDSS) provides a qualitative measure that allows tailoring of treatment. Mild axillary, palmar, and plantar hyperhidrosis (HDSS score of 2) should initially be treated with topical aluminum chloride (AC). If the patient fails to respond to AC therapy, botulinum toxin A (BTX-A; axillae, palms, soles) and iontophoresis (palms, soles) should be the second-line therapy. In severe cases of axillary, palmar, and plantar hyperhidrosis (HDSS score of 3 or 4), both BTX-A and topical AC are first-line therapy. Iontophoresis is also first-line therapy for palmar and plantar hyperhidrosis. Craniofacial hyperhidrosis should be treated with oral medications, BTX-A, or topical AC as first-line therapy. Local surgery (axillary) and endoscopic thoracic sympathectomy (palms and soles) should only be considered after failure of all other treatment options.

CONCLUSIONS These guidelines offer a rapid method to assess disease severity and to treat primary focal hyperhidrosis according to severity.