This document addresses various treatments of hyperhidrosis, a condition characterized by excessive sweating.

Note: For information regarding other uses for the technologies addressed in this document please see:

• CG-MED-28 Iontophoresis for Medical Indications
• DRUG.00006 Botulinum Toxin

Medically Necessary:

Iontophoresis is considered medically necessary in the treatment of primary or secondary hyperhidrosis only for individuals who have tried prescription strength antiperspirants without success and meet any ONE of the following criteria:

• Presence of medical complications or skin maceration with secondary infection; or
• Significant functional impairment, as documented in the medical record.

Botulinum toxin is considered medically necessary in the treatment of primary hyperhidrosis only for those individuals who have failed a 6 month trial of any one or more types of nonsurgical treatment (i.e., topical dermatologics such as aluminum chloride, tannic acid, glutaraldehyde, anticholinergics; systemic anticholinergics, tranquilizers or non steroid anti-inflammatory drugs) and meet any ONE of the following criteria:

• Presence of medical complications or skin maceration with secondary infection; or
• Significant functional impairment, as documented in the medical record.

Botulinum toxin is considered medically necessary in the treatment of secondary hyperhidrosis when the condition is related to surgical complications and both of the following criteria are met:

• Presence of medical complications or skin maceration with secondary infection; and
• Significant functional impairment, as documented in the medical record.

Treatment of primary axillary or palmar hyperhidrosis with endoscopic thoracic sympathectomy is considered medically necessary in the small subset of individuals with hyperhidrosis where both of the following criteria (1 and 2) have been met:

1. It has been adequately documented that all efforts at nonsurgical therapy have failed; and
2. Either of the following:
   • Presence of medical complications or skin maceration with secondary infection; or
   • Significant functional impairment, as documented in the medical records;

Not Medically Necessary:

Treatment of hyperhidrosis is considered not medically necessary when the above criteria are not met.

Investigational and Not Medically Necessary:

Treatment of plantar hyperhidrosis with thoracic or lumbar sympathectomy or sympathetic block is considered investigational and not medically necessary in all cases.

All other therapies for hyperhidrosis are considered investigational and not medically necessary, including but not limited to axillary liposuction, or resection of axillary sweat glands.

The medical necessity of treatment for hyperhidrosis focuses on those cases that result in significant functional impairment including medical complications, such as skin maceration or interference with activities of daily living.  The following therapies have been shown to be effective in the treatment of hyperhidrosis.

• Aluminum chloride; aluminum chloride is a common component of over-the-counter antiperspirants, although a prescription product is available (Drysol).
• Iontophoresis; iontophoresis (the use of an electric current to introduce various ions through the skin) is a long-standing treatment of palmar or plantar hyperhidrosis, with a reported success rate of up to 85%.  It has been adapted for axillary hyperhidrosis (Drott, 1995).
• Botulinum toxin; randomized studies have reported that botulinum toxin is associated with a decrease in palmar and axillary hyperhidrosis.  Case series have reported successful treatment of secondary gustatory hyperhidrosis (Lin, 2002; Lowe, 2002; Naver, 2000; Naumann, 2003).
• Thoracic sympathectomy for palmar or axillary hyperhidrosis; large case series have reported that thoracic sympathectomy is an effective treatment of palmar hyperhidrosis in 98% of cases.  The sympathectomy is frequently performed endoscopically (Ong, 2002; Park, 2000).

The available evidence addressing the use of either thoracic or lumbar sympathectomy for the treatment of plantar hyperhidrosis is extremely limited.  The most robust study published to-date included 30 women randomized to receive either thoracic sympathectomy or no surgical intervention (Loureiro, 2008).  The authors reported 20% of surgical subjects suffered prolonged post-operative pain, and that 53.3% experienced significant worsening compensatory hyperhidrosis.  The largest study available was published by Neumayer and included 73 subjects, 66 of whom had plantar hyperhidrosis (2005).  Subjects in this study were treated with an endoscopically placed clip to the thoracic sympathetic ganglion.  The authors reported that 42% of participants had significant improvements in their conditions, with 42.4% having no changes.  Interestingly, 15.2% of participants had exacerbated symptoms postoperatively.  Compensatory sweating occurred in 19.4% of subjects and 31.9% had gustatory sweating.  Kim et al. reported the results of a series of 69 subjects with plantar hyperhidrosis treated with chemical lumbar sympathetic block (2008).  Of the 138 procedures completed, only 68 (70%) were successful and successful treatment was seen in 72.2% of subjects.  Complications included temporary sexual dysfunction in one subject, compensatory hyperhidrosis in another, and significant post-block pain in three subjects.  Other smaller case series studies have been conducted.  Rieger and colleagues studied 8 subjects who underwent lumbar sympathectomy for plantar hyperhidrosis (2007).  A large proportion of study subjects experienced compensatory sweating (62%) and 50% had post-operative neuralgia.  A study by Singh and colleagues discussed a small trial of thoracic sympathectomy in 49 participants with plantar hyperhidrosis (2002).  The authors reported a 90% success rate in treating plantar hyperhidrosis, with a 13% rate of compensatory sweating.  Finally, Jani described a series of 7 subjects who underwent lumbar sympathectomy (2009).  The authors did not adequately report the outcome of the procedure in terms of successful treatment of the plantar hyperhidrosis, but did report one subject with spontaneously resolving upper thigh parasthesias.  No compensatory hyperhidrosis was reported.

Overall, the available body of evidence addressing lumbar and thoracic sympathectomy for plantar hyperhidrosis is insufficient to allow adequate evaluation of safety and efficacy.  The available data indicates a high rate of complications and no long-term results have been presented.  Further large-scale studies are needed for this procedure.

There is inadequate data to permit conclusions regarding effectiveness for other therapies of hyperhidrosis, including, but not limited to surgical excision or liposuction of axillary tissues.  For example, the published literature only includes scattered case reports of surgical excision or liposuction (Shachor, 1994; Shelley, 1998; Shenq, 1987; Swinehart, 2000; Tsai, 2001).

Hyperhidrosis is a relatively uncommon condition of exaggerated perspiration due to excessive secretion of the eccrine sweat glands in amounts greater than required for physiologic needs of thermoregulation and electrolyte alteration.  Primary hyperhidrosis is idiopathic in nature, typically involving the hands (palmar), feet (plantar) or armpits (axillae).  Secondary hyperhidrosis can result from a variety of drugs, such as tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), or underlying disease/conditions, such as febrile disease, diabetes mellitus or menopause.  Gustatory hyperhidrosis may be primary or secondary in nature, but is usually considered separately from these two classes of hyperhidrosis.  As a primary condition, it is characterized by excessive sweating of the lips, nose, and forehead after eating certain foods.  As a secondary condition this sweating condition is the result of complications from surgery to the parotid gland and subsequent aberrant regenerating parasympathetic fibers.

The consequences of hyperhidrosis are primarily psychosocial in nature.  Excessive sweating may be socially embarrassing, may require several changes of clothing a day or result in staining of clothing or shoes.  In some situations, hyperhidrosis may interfere with the activity of daily living.  For example, palmar hyperhidrosis may interfere with those jobs that require detailed work with the hands.

Treatment of secondary hyperhidrosis naturally focuses on treatment of the underlying cause.  A variety of therapies have been investigated for primary hyperhidrosis, including topical therapy with aluminum chloride or tanning agents, iontophoresis, botulinum toxin and endoscopic transthoracic sympathectomy.  Botulinum toxin has also been investigated as a treatment of secondary gustatory hyperhidrosis.

Description of Technologies

Aluminum Chloride:  Aluminum chloride is a common component of over-the-counter antiperspirants, although a prescription product is available (Drysol^®).  Aluminum chloride inhibits sweating by shrinking the secretory cells in sweat glands.  Aluminum chloride is predominantly used to treat axillary hyperhidrosis and not palmar or pedal hyperhidrosis.  Such aluminum chloride-based antiperspirants need to be applied directly to the affected area of skin once a week.

Iontophoresis:  This therapy involves the introduction of an electrical current through the skin using water as a medium.  Iontophoresis is a long-standing treatment of palmar or plantar hyperhidrosis and more recently axillary primary hyperhidrosis, with a reported success rate of up to 85%.  The mechanism of action is not precisely known, but is thought to be related to plugging of the sweat gland pores.  The typical device consists of water filled trays containing electrodes.  The individual inserts the hands or feet or positions the device in the axilla, and the current is turned on.  Individuals are treated for approximately 20 minutes, with treatments every 2 to 5 days for 5 to 10 sessions before an effect is observed.  Maintenance therapy may be required every 2 weeks after a normal level of sweating is achieved.  Treatment may be uncomfortable and in some cases painful.  Several iontophoresis devices have been approved by the FDA.  There are some machines that can only be used by physicians in an office setting.  However, there are currently two commercially available machines intended for home use by individuals with a prescription.  These devices are the Drionic^® device (General Medical Co., Los Angeles, CA) and the Fisher™ MD-1a Galvanic Unit (R.A. Fischer Co., Northridge, CA.).

Pharmacologic Therapy:  Some classes of drugs, including anticholinergics and some anti-inflammatory agents have been identified to help with this condition.  These drugs work by either interfering with the function of the sympathetic nervous system or in other ways altering the function of the body to decrease perspiration.  The use of drugs is common in conjunction with iontophoresis therapy.

Botulinum toxin:  Botulinum toxin is a potent neurotoxin that paralyzes muscle fibers when injected into targeted areas, and has been investigated and used as a treatment of hyperhidrosis.  Injection of botulinum toxin into the site of excessive sweating exerts a paralyzing effect on eccrine glands (sweat producing glands) that significantly decreases sweating in the treated area.  This treatment has been referred to as "chemodenervation of eccrine glands", indicating that the botulinum toxin has been used to block inervation of these glands.  Despite the reduction in sweating, treatment does not affect the unpleasant odor, perhaps due to the lack of effect of Botulinum toxin on the apocrine (scent producing) glands.  Treatment with Botulinum toxin has been reported to be effective for up to 2 to 7 months following injections.  Complications of treatment include weakness in adjacent muscles when injected into the hands and feet, and compensatory sweating (a generalized increase in sweating over the whole body).

Sympathectomy: Sympathectomy involves the surgical cutting of the nerve that stimulates sweat glands.  This surgical procedure can be done openly or endoscopically and is usually reserved for palmar, axillary, and craniofacial hyperhidrosis.  Although successful results have been reported to be up to 95% in some studies, significant complications have been noted.  Such complications include worsening of hyperhidrosis symptoms, gustatory hyperhidrosis, wound infection, puncture of the chest wall, and several complications involving the nerves of the ribs.

Eccrine gland: A gland in the skin that secretes sweat.  These glands are located all over the body, and greater concentrations may be found in certain areas of the body such as the armpits, feet, and others.

Hyperhidrosis: Severe and uncontrollable localized sweating of the scalp, torso (truncal), face (facial) hands (palmar), underarms (axillary), or the feet (plantar or pedal).

Iontophoresis: The passing of an ionized substance through intact skin by the application of a direct electrical current.

Liposuction: A surgical approach that uses a vacuum to remove fatty tissue from under the skin.

Primary hyperhidrosis: Hyperhidrosis due to unknown causes.

Secondary hyperhidrosis: Hyperhidrosis that results from an underlying cause; some common causes include prescribed drug side-effects and medical conditions such as anxiety disorders, diabetes mellitus, and menopause.

Secondary gustatory hyperhidrosis: A nervous system disorder characterized by severe sweating of the forehead, upper lip and mouth region, or chest that may result from exposure to spicy foods and complications from surgery to the parotid gland.

Sympathectomy: A surgical procedure during which segments of the sympathetic nerves that stimulate sweating are cut. This procedure interrupts the nerve transmissions that lead to excessive sweating.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary, when criteria are met: 

When services are Not Medically Necessary:
For the procedure and diagnosis codes listed above when criteria are not met, or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

When services are Investigational and Not Medically Necessary:

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

Peer Reviewed Publications:

1. Bachmann K, Standl N, Kaifi J, et al. Thoracoscopic sympathectomy for palmar and axillary hyperhidrosis: four-year outcome and quality of life after bilateral 5-mm dual port approach. Surg Endosc. 2009; 23(7):1587-1593.
2. Dressler D. Routine use of Xeomin in patients previously treated with Botox: long term results. Eur J Neurol. 2009; 16 Suppl 2:2-5. 
3. Drott C, Gothberg G, Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol. 1995; 33(1):78-81.
4. Jani K. Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis. J Am Coll Surg. 2009; 209(2):e12-15. 
5. Kim WO, Yoon KB, Kil HK, Yoon DM. Chemical lumbar sympathetic block in the treatment of plantar hyperhidrosis: a study of 69 patients. Dermatol Surg. 2008; 34(10):1340-1345.
6. Lawrence CM, Lonsdale Eccles AA. Selective sweat gland removal with minimal skin excision in the treatment of axillary hyperhidrosis: a retrospective clinical and histological review of 15 patients. Br J Dermatol. 2006; 155(1):115-118.
7. Levit F. Treatment of hyperhidrosis by tap water iontophoresis. Cutis. 1980; 26(2):192-194.
8. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopy thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis. analysis of 2000 cases. Neurosurgery. 2002; 51(5 Suppl):84-87.
9. Loureiro Mde P, de Campos JR, Kauffman P, et al. Endoscopic lumbar sympathectomy for women: effect on compensatory sweat. Clinics (Sao Paulo). 2008; 63(2):189-196.
10. Lowe NJ, Yamauchi PS, Lask GP, et al. Efficacy and safety of botulinum toxin type A in the treatment of palmar hyperhidrosis: a double-blind, randomized, placebo-controlled study. Dermatol Surg. 2002; 28(9):822-827.
11. Lowe NJ, Glaser DA, Eadie N, et al. North American Botox in Primary Axillary Hyperhidrosis Clinical Study Group. Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety. J Am Acad Dermatol. 2007; 56(4):604-611.
12. Miller D, Force S. Temporary thoracoscopic sympathetic block for hyperhidrosis. Ann Thorac Surg. 2008; 85(4):1211-1214.
13. Naumann M, Lowe NJ, Kumar CR, Hamm H; Hyperhidrosis Clinical Investigators Group. Botulinum toxin type A is a safe and effective treatment for axillary hyperhidrosis over 16 months: a prospective study. Arch Dermatol. 2003; 139(6):731-736.
14. Naumann MK, Hamm H, Lowe NJ. Botox Hyperhidrosis Clinical Study Group. Effect of botulinum toxin type A on quality of life measures in patients with excessive axillary sweating: a randomized controlled trial. Br J Dermatol. 2002; 147(6):1218-1226.
15. Naumann M, Lowe NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomized, parallel group, double blind, placebo controlled trial. BMJ. 2001; 323(7317):596-599. 
16. Naver H, Swartling C, Aquilonius SM. Palmar and axillary hyperhidrosis treated with botulinum toxin: one year clinical follow-up. Eur J Neurol. 2000; 7(1):55-62.
17. Neumayer C, Panhofer P, Zacherl J, Bischof G. Effect of endoscopic thoracic sympathetic block on plantar hyperhidrosis. Arch Surg. 2005; 140(7):676-680.
18. Odderson IR. Hyperhidrosis treated by botulinum A exotoxin. Dermatol Surg. 1998; 24(11):1237-1241.
19. Ong WC, Lim TC, Lim J, et al. Suction curettage; treatment for axillary hyperhidrosis and hidradenitis. Plast Reconstruct Surg. 2003; 111(2):958-959.
20. Park S. Very superficial ultrasound-assisted lipoplasty for the treatment of axillary osmidrosis. Aesth Plast Surg. 2000; 24(4):275-279.
21. Rieger R, Pedevilla S. Retroperitoneoscopic lumbar sympathectomy for the treatment of plantar hyperhidrosis: technique and preliminary findings. Surg Endosc. 2007; 21(1):129-135.
22. Shachor D, Jedeikin R, Olsfanger D, et al. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 sympathectomies. Arch Surg. 1994; 129(3):241-244.
23. Shelley WB, Talanin NY, Shelley ED. Botulinum toxin therapy for palmar hyperhidrosis. J Am Acad Dermatol. 1998; 38(2 Pt 1):227-229.
24. Shenaq SM, Spria M, Christ J. Treatment of bilateral axillary hyperhidrosis by suction assisted lipolysis technique. Ann Plast Surg. 1987; 19(6):548-551.
25. Rodriguez PM, Freixinet JL, Hussein M, et al. Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients. Eur J Cardiothorac Surg. 2008; 34(3):514-519.
26. Singh B, Shaik AS, Moodley J, et al. Limited thoracoscopic ganglionectomy for primary hyperhidrosis. S Afr J Surg. 2002; 40(2):50-53.
27. Swinehart JM. Treatment of axillary hyperhidrosis: combination of the starch-iodine test with the tumescent liposuction technique. Dermatol Surg. 2000; 26(4):392-396.
28. Tsai RY, Lin JY. Experience of tumescent liposuction in the treatment of osmidrosis. Dermatol Surg. 2001; 27(5):446-458.

Government Agency, Medical Society, and Other Authoritative Publications: 

1. In: DrugPoints System [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Available at: http://www.thomsonhc.com. Accessed on: September 7, 2011.
   • AbobotulinumtoxinA
   • IncobotulinumtoxinA
   • OnabotulinumtoxinA
   • RimabotulinumtoxinB
2. Online: Botulinum toxin monograph. April 20, 2011. American Hospital Formulary service (AHFS). Available at: http://www.ahfsdruginformation.com/. Accessed on September 7, 2011.

1. American Family Physician. Palmoplantar Hyperhidrosis: A Therapeutic Challenge. March 1, 2004. Available at: http://www.aafp.org/afp/20040301/1117.html.  Accessed on September 7, 2011.
2. The Society of Thoracic Surgeons. Hyperhidrosis.  Available at: http://www.sts.org/patient-information/other-types-surgery/hyperhidrosis.  Accessed on September 7, 2011.

Botox^®
Botulinum Toxin
Drionic^®
Drysol^®
Dysport^®
Fisher™ MD-1a Galvanic Unit
Hyperhidrosis
Iontophoresis
Myobloc^®
Xeomin^®

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.