Category: Topical

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Primary Hyperhidrosis: A Review of Epidemiology, Pathophysiology and Management

Acta Derm Venereol. 2026 Sep 16;106. doi: 10.2340/actadv.v106.adv-2026-0770.

ABSTRACT

Primary hyperhidrosis is termed as excessive sweating exceeding the physiological needs of thermoregulation. This review provides an updated overview focusing on epidemiology, quality of life, pathophysiology, economic impacts, diagnostic approaches and current management strategies. A literature search was conducted in June 2026 across PubMed and the Cochrane Central Register of Controlled Trials. Additional references were identified through manual searches of relevant bibliographies. Reported prevalence of hyperhidrosis varied widely, likely reflecting differences in methodology and disease recognition. Primary hyperhidrosis is associated with autonomic dys-regulation involving sympathetic pathways. Emerging evidence suggests that molecular alterations in eccrine glands may represent secondary adap-tations to sustained cholinergic stimulation, while genetic variability in receptor expression may contribute to interindividual differences in disease severity. Hyperhidrosis has a strong negative impact on the economy and quality of life, adversely affecting both mental and physical health. Multiple treatment options are available, including topical therapies, systemic agents, device-based interventions, botulinum toxin injections, and surgery. Despite increasing recognition of the clinical burden, comprehensive economic evaluations remain limited, with indirect costs and long-term societal impact insufficiently characterized. In conclusion, primary hyperhidrosis imposes a substantial burden on affected individuals, requiring improved re-cognition, standardized diagnostic frameworks, and individualized management strategies supported by high-quality and longitudinal research.

PMID:42747166 | DOI:10.2340/actadv.v106.adv-2026-0770

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A 1% glycopyrronium bromide cream for topical treatment of severe primary axillary hyperhidrosis in adolescents: safety, local tolerability, systemic exposure and efficacy from an open-label phase II study

J Dtsch Dermatol Ges. 2026 Sep 15. doi: 10.1111/ddg.70469. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Primary axillary hyperhidrosis (PAHH) results from dysregulation of the autonomic nervous system and typically begins during puberty. Treatment options for adolescents remain limited. This open-label phase II study evaluated the safety, local tolerability, systemic exposure, and efficacy of 1% GPB cream over 8 weeks in adolescents with severe PAHH.

PATIENTS AND METHODS: A total of 42 adolescents (23 male [55%] and 19 female [45%]; aged 12-17 years) applied the cream once daily for the first 4 weeks and thereafter as needed (at least twice weekly but no more than once daily). The primary endpoints assessed adverse drug reactions (ADRs), local tolerability, and systemic glycopyrronium exposure. Changes in sweat production, PAHH severity, and quality of life were assessed in all patients.

RESULTS: Two patients experienced mild ADRs (dry eye and increased conjugated bilirubin in one patient each); no serious adverse events occurred. All 40 evaluable patients had a skin reaction score of 0 throughout treatment. Total sweat production decreased significantly from baseline to day 29 (p < 0.001) and day 57 (p < 0.001). Patient-rated hyperhidrosis severity (PRHS) and quality of life, assessed using the Children’s Dermatology Life Quality Index (CDLQI), also improved significantly at both time points (all p < 0.001).

CONCLUSIONS: 1% GPB cream showed favorable safety and tolerability and improved clinical outcomes in adolescents with severe PAHH, consistent with findings in adults.

PMID:42745527 | DOI:10.1111/ddg.70469

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Botulinum toxin A for primary axillary hyperhidrosis: a narrative review

J Med Life. 2026 Jun;19(6):420-425. doi: 10.25122/jml-2026-0005.

ABSTRACT

Primary axillary hyperhidrosis (PAH) markedly impairs psychosocial well-being and daily functioning. Botulinum toxin type A (BoNT-A) is widely used, both on- and off-label, to suppress eccrine sweating through presynaptic inhibition of acetylcholine release and temporary chemodenervation of cholinergic sympathetic fibers. This narrative review synthesizes published clinical evidence between 2000 and January 2025 regarding the efficacy, durability, safety, and quality-of-life outcomes of BoNT-A for PAH, with comparative consideration of toxin formulations, injection techniques, and device-based alternatives. Evidence from randomized trials, prospective cohorts, long-term observational studies, and meta-analyses consistently demonstrates that intradermal BoNT-A achieves substantial axillary sweat reduction, often exceeding 50-80%, with improvement of at least two grades on the Hyperhidrosis Disease Severity Scale and meaningful reductions in Dermatology Life Quality Index scores. Treatment effects typically persist for approximately 4-7 months per cycle and are associated with predominantly mild, localized adverse events. Comparative data indicate similar efficacy among onabotulinumtoxinA, incobotulinumtoxinA, and abobotulinumtoxinA when equivalent dosing and standardized mapping techniques are applied. Injection strategy, particularly multi-point intradermal delivery guided by starch-iodine mapping, influences coverage and durability. Energy-based modalities-including microwave thermolysis and fractional microneedle radiofrequency-reduce sweating via device-mediated thermal targeting of eccrine glands and show variable comparative outcomes versus intradermal BoNT-A in durability, downtime, and cost. Overall, BoNT-A remains a well-supported first-line injectable therapy for PAH refractory to topical treatment, while further head-to-head and cost-effectiveness studies remain warranted.

PMID:42602382 | PMC:PMC13474375 | DOI:10.25122/jml-2026-0005

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Efficacy and safety of topical sofpironium bromide in treating primary axillary hyperhidrosis: systematic review and meta-analysis of randomized controlled trials

Dermatol Reports. 2026 Jun 16. doi: 10.4081/dr.2026.10853. Online ahead of print.

ABSTRACT

This systematic review and meta-analysis aimed to comprehensively evaluate the efficacy and safety of topical sofpironium bromide in patients with primary axillary hyperhidrosis (PAH) in various published randomized controlled trials (RCTs). The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched PubMed, Scopus, Web of Science, Embase, and Medline databases through April 30, 2025, using keywords related to sofpironium and PAH. The odds ratio (OR) or mean difference (MD) was calculated using a random effects model with 95% confidence interval (CI). Three RCTs of sofpironium were included in the meta-analysis, with 1,209 patients with PAH. Sofpironium, compared to the vehicle, showed statistically significant improvement in the Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax) score (OR=2.35, 95% CI [1.82 to 3.04]), Hyperhidrosis Disease Severity Scale (HDSS) score (OR=2.02, [1.46 to 2.79]), Dermatology Life Quality Index (DLQI) score (MD=-2.75, [-3.58 to -1.92]), and gravimetric sweat production (MD=-26.39, [-44.65 to -8.12]). The incidences of anticholinergic adverse events (AEs) and application site AEs were statistically higher in patients treated with sofpironium. Sofpironium is an effective treatment for PAH associated with significant improvements in sweat reduction and QOL for patients, although the drug also has risks of anticholinergic or application-site AEs.

PMID:42299704 | DOI:10.4081/dr.2026.10853

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Sofpironium Bromide for the Treatment of Primary Axillary Hyperhidrosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Cureus. 2026 May 9;18(5):e108570. doi: 10.7759/cureus.108570. eCollection 2026 May.

ABSTRACT

Sofpironium bromide is a recently approved topical anticholinergic agent for primary axillary hyperhidrosis, developed using a retrometabolic approach to limit systemic side effects. However, randomized evidence about its effects has not yet been quantitatively synthesized. This meta-analysis aimed to assess the efficacy and safety of topical sofpironium bromide compared with a vehicle in patients with primary axillary hyperhidrosis. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing topical sofpironium bromide with a vehicle. Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using random-effects models in Review Manager 7.2.0 (The Cochrane Collaboration, London, UK). Five RCTs, including 1,398 participants, were included, of whom 807 (57.7%) received topical sofpironium bromide. Compared with vehicle, sofpironium bromide significantly reduced gravimetric sweat production (GSP) at the end of treatment (MD -25.27 mg; 95% CI -40.15 to -10.40) and increased the likelihood of achieving at least a two-point improvement in the Hyperhidrosis Disease Severity Scale (HDSS) (RR 3.27; 95% CI 1.57-6.80). Discontinuation due to adverse events was more frequent in the sofpironium bromide group (RR 9.83; 95% CI 1.82-53.17). Adverse events occurred more frequently in the treatment group, including application-site dermatitis (RR 5.26; 95% CI 2.05-13.48), application-site pain (RR 4.63; 95% CI 2.08-10.28), pruritus (RR 5.97; 95% CI 1.98-18.02), and dry mouth (RR 15.45; 95% CI 5.35-44.62). No significant increase in serious adverse events was observed. Overall, this meta-analysis supports the efficacy of sofpironium bromide for primary axillary hyperhidrosis, while treatment decisions should be weighed against potential side effects.

PMID:42272574 | PMC:PMC13246317 | DOI:10.7759/cureus.108570

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Efficacy and Safety of Topical Anticholinergics in the Treatment of Primary Axillary Hyperhidrosis: A Systematic Review and Meta-analysis

Clin Drug Investig. 2026 Apr 16. doi: 10.1007/s40261-026-01550-2. Online ahead of print.

ABSTRACT

BACKGROUND: Topical anticholinergic agents are non-invasive treatment options for primary axillary hyperhidrosis (PAH). Sofpironium bromide was recently approved by the US Food and Drug Administration (FDA). A comprehensive evaluation of the efficacy and safety of available topical anticholinergics may inform clinical practice.

OBJECTIVES: To assess the efficacy and safety of topical anticholinergic therapies for PAH through systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS: Five databases were searched on September 9, 2024. Primary outcomes included a ≥2-point improvement in the Hyperhidrosis Disease Severity Scale (HDSS) and ≥50% reduction in gravimetric sweat production (GSP). Secondary outcomes included subjective symptom improvement and objective sweat reduction. Safety outcomes included treatment-emergent adverse events (TEAEs), anticholinergic-related adverse events, and local application site reactions. The review protocol was registered in PROSPERO (CRD42024583376).

RESULTS: Eight RCTs (n = 1921) that evaluated glycopyrronium, sofpironium bromide, and umeclidinium were included. Topical agents significantly outperformed placebos for HDSS ≥2-point improvement (risk ratio [RR]: 2.40; 95% confidence interval [CI]: 2.01-2.86) and GSP ≥50% reduction (RR: 1.43; 95% CI: 1.21-1.70). Sofpironium was the most effective HDSS treatment, whereas glycopyrronium showed highest efficacy against GSP. Topical agents were associated with increased risk of TEAEs (RR: 1.43; 95% CI: 1.14-1.79), with sofpironium associated with highest risk of dry mouth and glycopyrronium with highest risks for mydriasis and constipation.

CONCLUSIONS: Topical anticholinergic agents are effective for PAH treatment, with distinct efficacy and safety profiles. Although the available evidence is limited by the small number of trials, short follow-up durations, and heterogeneity in outcome reporting, these findings support the role of topical anticholinergic therapy as an effective non-invasive option for PAH.

PMID:41989535 | DOI:10.1007/s40261-026-01550-2

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Advances in pharmacological treatment and management of hyperhidrosis

Expert Opin Pharmacother. 2026 Mar 23:1-10. doi: 10.1080/14656566.2026.2642213. Online ahead of print.

ABSTRACT

INTRODUCTION: Hyperhidrosis is a functional disorder characterized by excessive sweat production beyond physiological needs for thermoregulation, significantly impairing quality of life, affecting physical comfort, psychological well-being, social interactions, and work productivity.

AREAS COVERED: This review focuses on evidence-based therapeutic options for hyperhidrosis. Topical treatments (glycopyrronium bromide, glycopyrronium tosylate, aluminum salts), systemic therapy (oral oxybutynin), injectable approaches (botulinum toxin), iontophoresis, and surgical interventions (local excision, sympathectomy) are discussed in detail. Clinical studies demonstrate that topical and systemic agents are effective for localized and multisite forms, respectively, while botulinum toxin offers strong efficacy for focal hyperhidrosis. The review also addresses combination strategies, treatment tolerability, cost-effectiveness, and patient-centered approaches.

EXPERT OPINION: Managing hyperhidrosis requires a nuanced, individualized strategy that balances symptom control, safety, patient preferences, and quality of life. Combination therapies and flexible treatment sequencing can reduce early reliance on invasive procedures. Despite therapeutic advances, widespread adoption is limited by heterogeneous guidelines, off-label use, and under-recognition of psychosocial impact. Future research should focus on prospective, large-cohort studies, standardized outcome measures, and development of selective, well-tolerated therapies. While a universal cure is unlikely, sustained symptom control and meaningful improvement in quality of life represent realistic objectives.

PMID:41871366 | DOI:10.1080/14656566.2026.2642213

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A significant gap between inadequate pharmacotherapy and substantial unmet needs in palmar hyperhidrosis management in China: insights from a questionnaire-based survey among outpatients

Front Pharmacol. 2026 Jan 8;16:1715189. doi: 10.3389/fphar.2025.1715189. eCollection 2025.

ABSTRACT

BACKGROUND: Palmar hyperhidrosis, characterized by excessive sweating primarily affecting the hands, significantly impairs quality of life and psychological well-being. Although topical agents, iontophoresis, microwave therapy, and sympathectomy are established interventions, real-world treatment patterns and pharmacotherapeutic adequacy among Chinese patients remain poorly delineated.

METHODS: An anonymous, questionnaire-based survey was conducted among consecutive patients at a tertiary thoracic surgery clinic in China between March 2023 and October 2024. A total of 363 valid responses were collected and analyzed using SPSS 27.0. Descriptive statistics and multivariable logistic regression were used to evaluate treatment patterns, patient preference, and predictors of treatment selection.

RESULTS: The study cohort was composed predominantly of individuals with severe disease (87.3% HDSS grade 3-4), and nearly all participants (97.8%) presented with palmar hyperhidrosis. Regarding treatment history, only 38.1% had previously received pharmacotherapy, while 32.6% had utilized Traditional Chinese Medicine (TCM) therapeutic approaches, including TCM, acupuncture, massage and manipulation therapies. Antiperspirants (28.6%) and TCM (25.0%) were the most frequently used prior pharmacotherapies, yet both were associated with limited therapeutic efficacy. According to our survey, owing to high symptom severity, 52.9% had a general knowledge of surgical intervention before the outpatient visit. Primary concerns regarding previous pharmacotherapy included insufficient efficacy and localized adverse effects, particularly skin irritation. Notably, 50.0% of participants remained receptive to future pharmacotherapy, showing a preference for topical formulations (29.3%) and reduced dosing frequency (31.6%). Gender and disease severity were identified as significant determinants of treatment choice. Importantly, prior negative experiences – such as inefficacy and side effects – did not significantly diminish willingness to consider future pharmacologic treatment.

CONCLUSION: Inadequate management and suboptimal treatment outcomes represent considerable challenges in the care of palmar hyperhidrosis in China. Existing pharmacotherapeutic options are constrained by limited availability, inadequate efficacy, and a narrow range of approved agents – a reality that highlights a critical disconnect with substantial patient demand. These findings underscore an urgent need to accelerate drug development and clinical translation in this field.

PMID:41585901 | PMC:PMC12823788 | DOI:10.3389/fphar.2025.1715189

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Hyperhidrosis: Diagnosis and management strategies

Nurse Pract. 2025 Oct 1;50(10):31-36. doi: 10.1097/01.NPR.0000000000000354. Epub 2025 Sep 25.

ABSTRACT

Hyperhidrosis, a condition characterized by an overactive cooling system that produces four to five times the normal amount of sweat, can profoundly impact a person’s physical, psychological, and social well-being. It can be classified as primary or secondary, and the location and severity determine treatment options. These options include topical agents, systemic agents, and nonsurgical and surgical procedures. Nurse practitioners play a crucial role in managing this condition, and their awareness and understanding are vital in designing effective treatment options for their patients. This article aims to enhance knowledge by discussing hyperhidrosis, its impact on a patient’s physical and psychological well-being, and recommended treatment modalities.

PMID:40996843 | DOI:10.1097/01.NPR.0000000000000354