The most commonly used medications for managing excessive sweating are anticholinergics. These include medicines such as glycopyrrolate, oxybutynin, benztropine, propantheline, and others.
Many hyperhidrosis patients experience success with anticholinergic therapy. Anticholinergics have not, however, been studied in controlled clinical trials specifically for hyperhidrosis. Their FDA approval is, on the other hand, based on studies involving other medical conditions. Their use for hyperhidrosis is thus “off-label”. Of course, it is common for medications to be used “off-label” and a substantial safe history of off-label use of these meds has helped many practitioners to feel confident about them. Some anticholinergics, such as glycopyrrolate and oxybutynin, have even been found to be safe in young children.
It should be noted, however, that more recent 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 by older people. Patients over (or near) the age of 65 may want to discuss these studies (JAMA Neurology 2016 and JAMA Internal Medicine 2015) with their physicians before embarking on or continuing anticholinergic therapy for excessive sweating.
Besides possibly in this older age group (and more studies are needed on this), anticholinergics do not, in general, affect the central nervous system (the brain and spinal cord). They work, instead, more peripherally by blocking the chemical messenger acetylcholine as it attempts to travel to receptors on the sweat glands that are responsible for triggering sweating. Similar receptors are, however, located in multiple areas of the body, so there can be a range of side effects from anticholinergic therapy such as dry mouth, constipation, impaired taste, blurred vision, urinary retention, and heart palpitations. These side effects can usually be managed by adjusting the individual’s dose. Of possible future use, a new medication that combines oxybutynin and pilocarpine (to combat dry mouth and other side effects) is being studied. David M. Pariser, MD, International Hyperhidrosis Society founding board member, and an expert in treating hyperhidrosis patients, characterize the side effects of anticholinergic treatments as “predictable, manageable and usually mild.”
That said, there are some hyperhidrosis patients who need to be cautious when using anticholinergics.
As mentioned above, patients age 65 or older may want to discuss their anticholinergic use and potential dementia risks with their clinicians, but other patients need to be careful and informed, too.
Because anticholinergic medications work systemically and cannot target any one body area, in particular, they decrease sweating over the entire body, even in those locations where sweating is not a problem. This overall decrease in sweating can put the patient at risk for overheating. Dee Anna Glaser, MD, president and founding board member of the International Hyperhidrosis Society, treats hundreds of hyperhidrosis patients a year and is well versed in anticholinergic use. She cautions her patients saying, “When taking anticholinergics, the body may have more difficulty keeping itself cool with the sweat mechanism ‘turned off.’ Therefore, athletes, people who participate in sports, people who work outdoors, and anyone who may potentially cause themselves injury by becoming overheated must use extra care when considering these treatments.” Patients or parents of children taking the medication must remain aware of temperature, water intake, exertion, and any symptoms of overheating such as pale skin, dizziness, muscle cramping, weakness, headache, and nausea.
Further, patients with glaucoma (especially narrow-angle glaucoma) and those who have impaired gastric emptying or a history or symptoms of urinary retention should not use anticholinergic therapy.
Two commonly prescribed anticholinergic medications are now available in liquid formulations, which is important and helpful for children who suffer from hyperhidrosis. Specifically, the FDA has approved a liquid form of the anticholinergic glycopyrrolate (brand name, Cuvposa) to reduce drooling in pediatric cerebral palsy patients. This new formulation of a commonly used anticholinergic medication offers an alternative for children who are unable or unwilling to swallow the pills. Oxybutynin is also available in a liquid formulation and is approved for use in pediatric patients with certain bladder and urinary conditions. Dr. Pariser says the benefits of oral anticholinergics in liquid form have been immediate. “I had an 8-year-old child who couldn't swallow the tablets, no matter how crushed or mixed with food. Here’s a great solution. And because this medicine is approved for children, it gives reassurance to patients of all ages who have safety concerns with this therapy.”
Beta Blockers and Benzodiazepines
There are other oral medications besides anticholinergics that are successful in treating patients with specific types of hyperhidrosis, as well. Beta-blockers (propranolol) and benzodiazepines work by “blocking” the physical manifestations of anxiety. These meds act on the central nervous system and are best for patients who experience episodic or event-driven hyperhidrosis (such as excessive sweating brought on by job interviews or presentations). Side effects limit their long-term use. For instance, benzodiazepines can be habit-forming, and many patients cannot tolerate the sedative effects caused by both of these drug therapies.
There have also been single-case or small samples of patients with specific types of hyperhidrosis who responded to a variety of other oral medications. Agents such as Clonidine, indomethacin, gabapentin, and multiple others have shown effectiveness in very specific cases of hyperhidrosis.
Some clinicians and their patients have had great success treating sweaty palms and sweaty feet by adding a crushed anticholinergic tablet to the water used during iontophoresis. Learn more about iontophoresis and how anticholinergics can make the process even more effective.
If you are interested in learning more about using oral medications to treat excessive sweating, find a healthcare provider who is well-versed in hyperhidrosis care and oral medications in the IHHS’s Clinician Finder database.
What if a systemic oral medication isn't right for you now? Maybe one will be in the future! Who knows what may become available! There are innovative developments on the horizon in hyperhidrosis care. But keep in mind, also, that there are great treatments available right now.
Have you talked to your medical provider about excessive sweating? If not, now is the time! Learn more about how you and your healthcare team can work together to find the right treatment, or combination of hyperhidrosis treatments, to manage your hyperhidrosis.
If you’re considering an oral medication to treat excessive sweating, please know that experts in the field recommend that you try antiperspirants, iontophoresis, or Botox injections first (or a combination of these). Click on the links provided to learn more about the usefulness of these treatments.
And remember, because hyperhidrosis is a serious medical condition - you deserve insurance coverage and reimbursement for your medical visits and treatments! We’ve got tips to help you navigate the health insurance realm and receive coverage.
Research and References
Want to learn more about oral medications for the treatment of excessive sweating? Below are links to relevant articles and abstracts published in medical journals. More studies regarding other treatments can be found here:
Pariser D, Krishnaraja J, Tremblay T, Rubison M, Love T, McGraw B. Randomized, Placebo- and Active-Controlled Crossover Study of the Safety and Efficacy THVD-102, a Fixed-dose Combination of Oxybutynin and Pilocarpine, in Subjects with Primary Focal Hyperhidrosis. Journal of Drugs in Dermatology 2017 Feb 1;16(2): 127-132.
Risacher SL, McDonald BC, Tallman EF, et al. "Association between anticholinergic medication use and cognition, brain metabolism, and brain atrophy in cognitively normal adults." JAMA Neurol. doi:10.1001/jamaneurol.2016.0508. Published online April 18, 2016.
Campbell, Noll L. PharmD & Boustani, Malaz A. MD, MPH. “Adverse cognitive effects of medications. Turning attention to reversibility.” Invited commentary. JAMA Intern Med doi: 10.1001/jamainternmed.2014.7667. Published online January 26, 2015.
Hund, Martina, et al. “Randomised, placebo-controlled, double-blind clinical trial for the evaluation of the efficacy and safety of oral methanthelinium bromide (Vagantin®) in the treatment of focal hyperhidrosis”.JDDG;2004· 2:343-349.