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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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Sustained efficacy of botulinum toxin in primary palmar hyperhidrosis: a systematic review of duration, quality of life, and satisfaction

Front Med (Lausanne). 2026 Mar 25;13:1795512. doi: 10.3389/fmed.2026.1795512. eCollection 2026.

ABSTRACT

BACKGROUND: Primary palmar hyperhidrosis (PPH) is a debilitating condition characterized by excessive sweating of the palms, significantly impairing patients’ quality of life (QoL). Botulinum toxin (BoNT) injections are a widely used treatment, but data on their sustained efficacy, impact on QoL, and patient satisfaction remain limited.

OBJECTIVE: This systematic review aimed to systematically evaluate the duration of BoNT efficacy, its effects on QoL, and patient-reported satisfaction and improvement in PPH.

METHODS: This systematic review followed PRISMA guidelines. PubMed, Cochrane Library, and Scopus databases were searched from 2005 to 2024. Studies included randomized controlled trials, observational studies, and clinical trials involving adults with PPH treated with BoNT injections. Outcomes included duration of efficacy, QoL measures (e.g., DLQI), and patient satisfaction.

RESULTS: Nineteen studies met inclusion criteria. The duration of BoNT efficacy ranged from 3 to 12 months, with BoNT-A demonstrating a mean efficacy of 4.9-9.5 months, while BoNT-B showed a shorter duration of 3.8-4.6 months. Higher doses and repeated injections were associated with prolonged symptom control. Disease severity influenced efficacy, with moderate cases experiencing longer relief compared to severe cases. QoL improvements were substantial, with Dermatology Life Quality Index (DLQI) scores showing significant reductions post-treatment. Patient satisfaction rates ranged from 65 to 100%, though this effect diminished over time.

CONCLUSION: BoNT is an effective and well-tolerated treatment for PPH, offering substantial symptom relief, improved QoL, and high patient satisfaction. Future research should focus on standardized protocols and long-term follow-up to optimize treatment strategies.

PMID:41958548 | PMC:PMC13056597 | DOI:10.3389/fmed.2026.1795512

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Oxybutynin treatment for episodic hyperhidrosis in Parkinson disease

J Parkinsons Dis. 2026 Apr 7:1877718X261440704. doi: 10.1177/1877718X261440704. Online ahead of print.

ABSTRACT

Not all medications arrive from a disciplined path of translational drug development; sometimes, the route of discovery involves serendipity. A drug developed for controlling urinary urgency, oxybutynin, is reviewed here as a highly effective treatment for excessive sweating (hyperhidrosis). Its use in Parkinson disease is described in a case report.

PMID:41944203 | DOI:10.1177/1877718X261440704

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Iodine-starch test validity in amputee patients with hyperhidrosis

Disabil Rehabil. 2026 Mar 30:1-13. doi: 10.1080/09638288.2026.2650049. Online ahead of print.

ABSTRACT

PURPOSE: Validate the iodine-starch test in amputees by comparing a novel measure, the Amputee Iodine-Starch Result (AISR) with the Hyperhidrosis Disease Severity Scale (HDSS) and to measure test-retest reliability in patients with hyperhidrosis.

MATERIALS AND METHODS: Amputee patients underwent iodine-starch testing using a previously described method. AISR was derived by visually inspecting sweat reactions on the residual limb and prosthetic sheath, scoring intensity using the Sweating Intensity Visual Scale (SIVS), measuring surface area involvement, and normalizing to residual limb surface area. Ordinal logistic regression for HDSS vs AISR was performed. Intraclass correlations (ICC) measured test-retest reliability.

RESULTS: 91 participants, including 25 control participants, underwent iodine-starch testing. The ordinal logistic regression for HDSS vs AISR on both skin (AISR-SK) (χ2 = 10.57, OR = 2.91 (95% CI 1.48-5.73), p = 0.0011) and sheath (AISR-SH) (χ2 = 8.62, OR = 2.10 (95% CI 1.26-3.51), p = 0.0033) was highly significant. ICC showed poor test-retest reliability for skin (AISR-SK, r = 0.388, ICC = 0.393, 95% CI 0.028-0.662) and sheath (AISR-SH, r = 0.194, ICC = 0.198, 95% CI -0.189, 0.526) measurements.

CONCLUSIONS: The iodine-starch test is significantly associated with HDSS, but has poor test-retest reliability.

PMID:41910115 | DOI:10.1080/09638288.2026.2650049

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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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Hyperhidrosis Improved by Samhwangsasim-Tang: A Case Report

Clin Cosmet Investig Dermatol. 2026 Jan 14;19:575693. doi: 10.2147/CCID.S575693. eCollection 2026.

ABSTRACT

Hyperhidrosis is a disorder characterized by excessive sweating beyond physiological requirements, which significantly interferes with daily functioning and quality of life. It affects approximately 4%-5% of the population worldwide, yet its underlying pathophysiology remains unclear, with proposed mechanisms involving autonomic nervous system dysregulation, metabolic imbalance, and psychological factors. Here, we describe a case of chronic hyperhidrosis in which spontaneous sweating and facial flushing improved markedly following administration of Samhwangsasim-tang as monotherapy. A 66-year-old man presented with chronic hyperhidrosis occurring without identifiable triggers. Even minimal physical activity caused profuse craniofacial sweating accompanied by facial flushing, which was exacerbated by heat exposure and conditions associated with increased core body temperature. Based on his symptom pattern, Samhwangsasim-tang extract granules were prescribed. No other treatments, including acupuncture, cupping therapy, or conventional medications, were administered during the treatment period. Symptom severity was evaluated using the Numeric Rating Scale (NRS) and the Hyperhidrosis Disease Severity Scale (HDSS). After approximately 42 days of treatment, spontaneous sweating resolved completely (NRS 10 → 0; HDSS 4 → 1), and facial flushing was reduced to 20%-30% of baseline severity (NRS 10 → 2-3). This case suggests that the heat-clearing, anti-inflammatory, and metabolic-regulating properties of Samhwangsasim-tang may contribute to the normalization of skin temperature, sweating regulation, and peripheral circulation. Further clinical and mechanistic studies are warranted to elucidate its therapeutic potential in hyperhidrosis.

PMID:41858595 | PMC:PMC12997260 | DOI:10.2147/CCID.S575693

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Advances in the Management of Hyperhidrosis

Skin Therapy Lett. 2026 Mar;31(2):4-7.

ABSTRACT

Hyperhidrosis (HH), a condition characterized by excessive sweating beyond thermoregulation, significantly impairs quality of life. Conventional medications to treat HH include aluminum chloride hexahydrate, systemic anticholinergics, and botulinum toxin injections. New treatments have emerged including glycopyrronium bromide, sofpironium bromide, targeted alkali thermolysis, and microwave devices. This paper reviews the mechanism of action, efficacy, safety, and practical considerations associated with these treatments.

PMID:41839170

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Prediction of compensatory hyperhidrosis severity after endoscopic thoracic sympathectomy in primary hyperhidrosis patients based on rough set analysis

J Thorac Dis. 2026 Feb 28;18(2):146. doi: 10.21037/jtd-2025-aw-2074. Epub 2026 Feb 25.

ABSTRACT

BACKGROUND: Compensatory hyperhidrosis (CH) remains the most prevalent postoperative adverse event following endoscopic thoracic sympathectomy (ETS) for primary hyperhidrosis (PH). Current predictive models lack reliability in estimating CH severity. This study introduces a novel predictive framework utilizing rough set theory to establish decision rules for CH stratification.

METHODS: In this single‑center retrospective cohort study, clinical data from 225 PH patients undergoing ETS were analyzed, including 37 predictive indicators. These variables were subjected to correlation analysis, regression analysis, and rough set analysis with CH severity.

RESULTS: There were 93.3% (210/225) of patients exhibiting CH following ETS, with 33.3% classified as grade III CH, and no grade IV CH was noted. Body mass index (BMI), the level of sympathectomy, and the temperature difference of the right hand after surgery and before anaesthesia were shown to be significantly correlated with CH on correlation analysis. However, no valid regression model was established with significant correlations involving indicators for further regression analysis. By switching to rough set analysis, four predictive rules for grade III CH were derived: (I) BMI >22 kg/m2 + initial onset age of PH >11 years, 84% accuracy; (II) BMI 19.5-22 kg/m2 + surgical age >28.5 years, 82% accuracy; (III) BMI 18.5-19.4 kg/m2 + postoperative right-hand temperature >36.6 ℃, 77% accuracy; (IV) BMI <18.5 kg/m2 + postoperative right-hand temperature <37.0 ℃ + initial PH onset age <10 years, 71% accuracy.

CONCLUSIONS: Rough set analysis provides a promising approach for exploring the patterns of CH severity following ETS in patients with PH, and thus which merits further investigation through multicenter, large-sample studies. The four preliminary decision rules for predicting grade III CH derived from rough set analysis show potential clinical relevance but remain tentative, as their utility requires validation in prospective cohorts prior to widespread clinical application.

PMID:41816421 | PMC:PMC12972784 | DOI:10.21037/jtd-2025-aw-2074