Exploring Oral Therapies for Hyperhidrosis: Current and Future Perspectives

Hyperhidrosis, characterized by excessive sweating beyond thermoregulatory needs, remains a challenging condition to manage comprehensively.

According to Adam Friedman, MD, FAAD, professor and chair of dermatology at the George Washington School of Medicine and Health Sciences in Washington, DC, there are emerging systemic therapies that complement existing options.

In an interview with Dermatology Times, Friedman examined the ways oral systemic therapies fit into the current treatment landscape and looked ahead to the promising and exciting innovations that are ahead.

Friedman noted, "While there isn’t a ton for the management of primary hyperhidrosis, we definitely have more than we’ve had in the past." He emphasized that even though most systemic options are off-label, dermatologists are skilled at "symbiotic combination therapies," often layering different treatments for better outcomes.

Current Oral Therapies in Focus

For patients with multifocal hyperhidrosis or those unresponsive to topicals, anticholinergics serve as a cornerstone of systemic therapy. Friedman highlighted glycopyrrolate as his preferred option. "I like glycopyrrolate because it does not cross the blood-brain barrier, so the central nervous system impact is minimized, versus oxybutynin, which tends to have more side effects," he said.

He advises starting glycopyrrolate at 1 milligram twice daily and allowing patients to adjust the dosage weekly, up to a maximum of 6 milligrams daily. This approach empowers patients while minimizing dose-dependent adverse effects like dry mouth and urinary retention.

When anticholinergics are insufficient, clonidine and propranolol can be considered. Clonidine is particularly useful for hyperhidrosis accompanied by flushing, while propranolol shines as a situational treatment. "Propranolol is great for the flop sweat individual...the person who goes on stage, and they go from zero to sauna in 10 milliseconds," said Friedman.

Looking Ahead: Emerging Options and Personalization

Innovation in hyperhidrosis treatment is paving the way for novel solutions, such as the recently approved topical sofpironium bromide (Sofdra; Botanix Pharmaceuticals).¹ Friedman explained that its unique formulation "limits the potential for anticholinergic side effects."

Friedman encouraged clinicians to familiarize themselves with emerging therapies. "One of the fun things about managing hyperhidrosis...is really that creativity, due to the diversity of all patients, that allows us to create a personalized management strategy," he stated.

Reference

1. FDA approval of Sofdra – the first new drug for primary axillary hyperhidrosis. News release. Botanix Pharmaceuticals. June 20, 2024. Accessed January 22, 2025. https://cdn-api.markitdigital.com/apiman-gateway/ASX/asx-research/1.0/file/2924-02819259-6A1212299