The Treatment of Primary Focal Hyperhidrosis

Todd Wechter, BSc; Steven R. Feldman, MD, PhD; Sarah L. Taylor, MD, MPH


Skin Therapy Letter. 2019;24(1) 

In This Article

Systemic Therapies

Systemic therapies are generally considered second- or thirdline options depending on disease severity and location.[8] The main class of oral medication prescribed for hyperhidrosis is anticholinergics, although antihypertensives and psychiatric medications have also been utilized.[61] Anticholinergic medications act through blocking sweat gland muscarinic receptor activation by acetylcholine (Figure 1C).[61] Although many anticholinergic medications are effective, there is some reluctancy to use them as a result of their side effect profile.[61–65]

In a 2012 prospective study investigating the efficacy and safety of low dose oral oxybutynin, approximately 35% and 39% of treated patients reported their quality of life as "much better" or "a little better," respectively.[62] This was compared to just 13.6% of patients in the placebo group reporting "a little better" quality of life, and none reporting "much better" quality of life.[62] Dry mouth was the only adverse effect noted during the study and was considered moderate to severe in 26.1% and 34.8% of patients receiving 5 mg and 10 mg oxybutynin therapy, respectively.[62]

Glycopyrrolate is another anticholinergic drug that has been studied in primary hyperhidrosis.[64] In one retrospective study including 31 pediatric patients with recalcitrant disease, oral glycopyrrolate therapy resulted in "major improvement" in 71% of treated patients.[64] The medication was generally well tolerated and the most common side effect was dry mouth.[64]

Methantheline bromide is additional systemic anticholinergic option.[61,65] In a 2013 multicenter clinical trial involving 339 patients with axillary or palmar disease, axillary sweat secretion was reduced 41% after 1 month of oral methantheline bromide treatment; no significant difference in palmar sweat production was noted.[65] Treated patients also experienced decreases in both HDSS and DLQI scores.[65] Similar to other anticholinergic medication studies, dry mouth was the most frequently experienced side effect.[65]

Research into methods of reducing the side effects of anticholinergic medications has also yielded some promising results.[63] For example, recent study of an oxybutynin/pilocarpine combination drug demonstrated both efficacy and a lower incidence of dry mouth.[63]

Side effects of anticholinergic medications generally include dry mouth, dry eyes, changes in vision, and decreased intestinal motility.[61,64,65] Caution must be exercised when prescribing these drugs, especially in patients that may experience urinary retention or acute closed angle glaucoma.[61] There is also literature suggesting that long-term anticholinergic use may be a risk factor for cognitive impairment.[66,67]