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Topical Treatments: Anticholinergics
Topical use of anticholinergic drugs could
theoretically avoid systemic side effects. However, sufficient
absorption through the skin to affect cholinergic nerve
endings may be a limiting factor, requiring higher concentrations
of drug that may lead to systemic absorption and side effects.[58]
Contact sensitization is also possible.[58]
Propantheline, scopolamine, and poldine methylsulfate are
among the anticholinergics used experimentally for hyperhidrosis.[58]
Topical propantheline delivered by aerosol was effective
in decreasing plantar sweating in institutionalized patients.[37]
Poldine methosulfate and glycopyrronium bromide were delivered
via iontophoresis in two different studies, with some reduction
in palmoplantar symptoms.[1,47]
Axillary hyperhidrosis did not respond as well, and systemic
side effects were noted in many patients, particularly when
higher doses were used.[1,47]
Topical glycopyrrolate in 0.5% cream was used
to treat gustatory hyperhidrosis in a series of patients
with diabetes.[128]
Compared to placebo, glycopyrrolate cream reduced forehead hyperhidrosis
during gustatory challenge by 82% (P<0.01).[128]
The frequency of episodes of gustatory sweating significantly
decreased during the period of active treatment.[128]
Glycopyrrolate is a quaternary ammonium anticholinergic
with limited central nervous system effects and higher anticholinergic
potency compared to atropine or scopolamine.[92]
In a single case report, a 0.5% topical solution of glycopyrrolate
effectively relieved primary craniofacial hyperhidrosis.[92]
Another anticholinergic agent, diphemanil
methylsulfate, was used successfully in 15 patients with
Frey’s syndrome.[81]
Compared to placebo, 2% diphemanil methylsulfate cream provided
partial symptom reduction in a third of patients and complete
reduction in 40% of patients. The effect lasted two to four days,
and two patients reported a dryness of the mouth, suggesting
some systemic absorption.
Peripheral nerve blockade by use of local
anesthetics could also lead to anhidrosis by blocking sympathetic
nerve transmission to eccrine sweat glands.[58]
Although a eutectic mixture of 5% lidocaine and 5% prilocaine
reduced palmar and axillary hyperhidrosis in 15 of 17 patients
for up to six hours, when used daily for three to four weeks, only
25% of the patients were satisfied with the therapy.[2,3,6,75]
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