A gradual stepwise approach should be the general guideline for treatment of hyperhidrosis. The effectiveness of less invasive methods should be tested before taking into consideration surgery. This principle is particularly true for facial hyperhidrosis where surgery is associated with an increased risk for severe compensatory sweating, as well as for hyperhidrosis of the armpits, where botulinum toxin delivers excellent results and has no side effects, surgery remaining a rarely needed option.
Only in extreme palmar hyperhidrosis, conservative treatment alternatives have such a limited success rate that surgery can be regarded a suitable option with an acceptable level of side effects at an early stage.
Aluminum Chloride -> Iontophoresis -> Thoracoscopic Surgery of the Sympathetic Chain
Anticholinergic drugs -> (Botulinum Toxin) -> Thoracoscopic Block of the Sympathetic Chain (ESB)
Aluminum Chloride -> Botulinum Toxin -> (Surgery)
Aluminum Chloride, Disinfectants + ev. Antimycotic agents -> Iontophoresis -> Lumbal Block of the Sympathetic Chain (ELS)
Also facial blushing requires a step by step treatment approach. After careful psychological evaluation and psychodynamic treatment, possibly supported by appropriate medication, a blockade of the sympathetic chain can be considered. Thereby should be taken into account that despite a properly executed operation which almost always is followed by excellent early results with complete suppression of blushing, the relapse rate is higher than in operations for hyperhidrosis.