Systemic medications may be used for the treatment of generalized or focal hyperhidrosis. They may be useful for patients with cranio-facial hyperhidrosis, focal hyperhidrosis affecting large areas such as the back, multifocal hyperhidrosis, hyperhidrosis that is not satisfactorily treated with other methods, or temporary, short-term event-specific hyperhidrosis management (ex. for a wedding, speech, or performance).
Many of the drugs reported useful for hyperhidrosis have not been studied in controlled trials, their use being based only on anecdotal evidence. Furthermore, at the doses likely to inhibit hyperhidrosis, side effects can be limiting. In addition, many of these drugs are not approved by the US Food and Drug Administration specifically for the treatment of hyperhidrosis.
The most commonly used agents are anticholinergics, which block the sympathetic stimulation of eccrine glands by inhibiting the action of acetylcholine at the synapse. Use of these drugs is limited, however, by the common side effects of the anticholinergic class—dry mouth, urinary retention, constipation, and visual disturbances such as mydriasis and cycloplegia.[9,19] It may be possible to manage such side effects by adjusting the dose. Of possible future use, a new medication that combines oxybutynin and pilocarpine (to combat dry mouth and other side effects) is being studied.
It should be noted that studies (in JAMA Neurology 2016 and JAMA Internal Medicine 2015) have reported a potential link between the development of dementia and/or brain atrophy and long-term, high-level anticholinergic use in patients over the age of 65.
Anticholinergics used for hyperhidrosis include propantheline, glycopyrronium bromide, oxybutynin, and benztropine. Anticholinergic therapy is generally not recommended in patients with glaucoma (especially narrow-angle glaucoma) and those who have impaired gastric emptying or a history or symptoms of urinary retention. Patients should be aware of risks of overheating when using anticholinergics. Athletes, people who work outdoors and anyone who may potentially cause themselves injury by becoming overheated must use extra care when utilizing these treatments. Patients or parents of children taking the medication must remain aware of temperature, water intake, exertion, and any symptoms of overheating.
Certain anticholinergic medications are available in liquid formulations, which may helpful for children who suffer from hyperhidrosis, including a liquid form of glycopyrrolate (Cuvposa) indicated to reduce drooling in pediatric cerebral palsy patients. Oxybutynin is also available in a liquid formulation; indicated for pediatric patients with certain bladder and urinary conditions.
Some physicians have had success treating palmar and/or plantar hyperhidrosis by adding a crushed anticholinergic to iontophoresis water.
When stressful situations are a trigger for hyperhidrosis, use of an anticholinergic agent or a benzodiazepine prior to an event likely to provoke anxiety may be helpful. Long-term use of benzodiazepines such as diazepam is limited by development of dependency, and many patients cannot tolerate the sedative effects of these drugs. Some patients are able to take diazepam 5 mg at bedtime for several weeks to get used to its sedating effect and then use it as needed for anxiety-provoking events.
There are reports of single cases or small series of patients with specific types of hyperhidrosis responding to a variety of systemic medications. Use the menu above to read about some of these case reports for individual medications: please roll over "Treatments", then "Systemic Medications", then choose the appropriate option.
For an extensive list of published medical literature related to hyperhidrisis, with links to abstracts and full text when available, click here.