“I actually prefer glycopyrrolate, because it does not cross the blood-brain barrier, so it is associated with fewer overall systemic and neurologic side effects,” Dr. Friedman said, noting that he starts with 1 mg twice daily, titrated slowly up to a maximum of 6 mg daily.
An oral solution is available, which is useful for treating children, he said, noting that data suggest anticholinergics can be very effective in children. In one recent study, 90% of 31 children treated with an average dose of 2 mg per day of glycopyrrolate experienced improvement (J. Am. Acad. Dermatol. 2012;67:918-23). In a review of 59 children treated with oxybutynin for palmar-plantar hyperhidrosis titrated up to 5 mg twice daily, 90% experienced improvement (Pediatr. Dermatol. 2014 Dec. 10 [doi:10.1111/pde.12385]). Central nervous system side effects were more common in the latter study, however.
The downside of using anticholinergics is the need for long-term therapy and the long list of possible side effects, including dry mouth, dry eyes, constipation, blurred vision, and urinary retention – among many others, he said.
For patients with hyperhidrosis due to social phobia and performance anxiety, consider using beta-blockers. Give 10-20 mg about an hour before performance, or 5 mg in those with low blood pressure, slow baseline heart rate, or very small body mass index. A trial run at home before a performance is advisable. A number of contraindications to beta-blocker use exist, including bradycardia, atrioventricular block, and asthma, just to name a few, Dr. Friedman said.
Minimally invasive treatment options include botulinum toxin injections and energy based treatments.
Botulinum toxin injections last 3-7 months and are quite effective, with 90% of patients reporting improvement, but they can be painful and are expensive at $1,400-$1,600 per treatment.
Among new and emerging treatments that show promise are MiraDry, a microwave energy technology approved in 2011 for axillary hyperhidrosis, and topical botulinum toxin, delivered without needles thanks to nanotechnology.
The latter is currently under development by at least two companies, and trials are underway. Early data suggest treatment reduces sweating by 40%, Dr. Friedman said.
Dr. Friedman reported having no relevant financial disclosures.