Hyperhidrosis

Drugs



The neurotransmitter and receptor between the peripheral autonomic nerve fiber and sweat gland is acetylcholine and muscarinic receptor respectively, so antimuscarinic agents may be useful.  These may be given orally, such as propantheline bromide 15 mg t.d.s., or topically.  Oral administration is convenient, but one may also get blockade of muscarinic receptors throughout the body with consequent side effects including dry mouth, constipation and a tendency to retention of urine.  An alternative is topical administration, although the issue here is finding an appropriate preparation of the drug such that it is not uncomfortable to apply, does not break down and manages to get across the outer keratin layer of the skin so it can reach the base of the sweat gland, but does not just pass completely systemically, in which case one might as well have just taken it orally in the first place.

Some patients use scopolamine patches, although this results in the drug scopolamine permeating throughout the entire body including the brain with important side effects.  Non-blood-brain barrier penetrant anticholinergics are preferable such as propantheline, although again have important systemic side effects.  Ergoloid mesylates, mecamylamine, atropine, propoxyphenel, dibenamine, piperoxan, phentolamine and methantheline bromide have all been described. A low dose of a beta-blocker such as atenolol or propanolol may also be useful given that a hyperadrenergic state (overactive sympathetic system) will exacerbate sweating.

Some people have a more active sympathetic system than others and going along with this is a quite frequent tendency to anxiety.  Having said that it may actually be that it is the end-organ response of the hyperadrenergic state (aging, palpitations, sweating) that feeds back to the brain and increases the level of anxiety.  Whatever, pragmatically addressing the anxiety may be helpful.  This may be treated through cognitive behavioral therapy or alternatively in more severe cases medications directed towards anxiety such as pregabalin, SSRIs or SNRIs.Alpha-2 agonists such as clonidine, beta-blockers, and calcium channel antagonists have been described as having a slight effect in single case reports. Clonidine in particular is thought to be more effective for menopause-related hyperhidrosis or hyperhidrosis secondary to antidepressants.  Fludrocortisone 0.3 mg daily has been used to control sweating in quadriplegics with orthostatic hypotension.