Advice
Intervention and alternatives
Glycopyrronium bromide is an antimuscarinic drug that prevents the stimulation of sweat glands and does not cross the blood brain barrier. Glycopyrronium bromide powder for solution (Robinul powder) is currently licensed for the iontophoretic treatment (electromotive drug administration) of primary (idiopathic) hyperhidrosis of the plantar (soles of feet) and palmar (palms of hands) skin.
Glycopyrronium bromide is also licensed as solution for injection for preoperative and intraoperative use, and in a single-dose dry-powder inhaler for treating chronic obstructive pulmonary disease.
No oral preparations (tablets and solution or suspension) of glycopyrronium bromide are licensed in the UK. The use of imported oral preparations or those prepared by specials manufacturers for treating hyperhidrosis in adults and children is unlicensed.
Glycopyrronium bromide (glycopyrrolate) tablets 1 mg and 2 mg (Robinul and Robinul Forte) are available in the USA, licensed for adjunctive therapy in the treatment of peptic ulcer. Glycopyrronium bromide (glycopyrrolate) 1 mg/5 ml oral solution (Cuvposa) was licensed in the USA in 2010 to reduce chronic severe drooling in children and young people aged 3–16 years with a neurological condition associated with problem drooling, such as cerebral palsy.
Condition
Hyperhidrosis is a condition in which sweating is in excess of that necessary to maintain normal body temperature. Primary (idiopathic) hyperhidrosis has no recognised cause and mainly affects focal areas of the body such as the soles of the feet (plantar hyperhidrosis) and palms of the hands (palmar hyperhidrosis), underarms (axillary area), or face and scalp. Onset of primary hyperhidrosis is usually before the age of 18 years. Primary hyperhidrosis affects males and females equally (Hyperhidrosis: CKS 2009).
Secondary hyperhidrosis is caused by another condition, such as hyperthyroidism or diabetes, neuropathy, or spinal disease or injury, or can be a side effect of a drug. Secondary hyperhidrosis can be generalised, affecting the whole body, or can affect only focal areas, similar to primary hyperhidrosis (Hyperhidrosis: CKS 2009).
Alternative treatment options
The first-line approach to treating primary hyperhidrosis usually involves self-help measures, such as personal care and use of antiperspirants containing 20% aluminium chloride hexahydrate (Hyperhidrosis: CKS 2009). Treating any underlying anxiety, which may be an exacerbating factor, should also be considered, with referral to a dermatologist if these measures are inadequate or unacceptable (Hyperhidrosis: CKS 2009).
Second-line treatments include:
-
iontophoresis (either tap water iontophoresis, or with glycopyrronium bromide [Robinul powder], which is licensed for primary hyperhidrosis of the hands and feet, added to the water)
-
botulinum toxin type A (Botox injection, which is licensed for treating severe hyperhidrosis of the axillae, which has not responded to topical treatment with antiperspirants)
-
oral antimuscarinics: propantheline bromide (Pro-Banthine tablets, which are licensed for hyperhidrosis), glycopyrronium bromide (unlicensed), oxybutynin (off-label)
-
surgery: resection or endoscopic thoracic sympathectomy
-
topical glycopyrronium bromide (unlicensed)
-
emollients and topical corticosteroids for treating irritation, different strengths of aluminium salts (up to 50%), and topical glutaraldehyde or formaldehyde
-
other treatments: clonidine, diltiazem, or benzodiazepines.
Managing secondary hyperhidrosis generally involves history taking, examination, and investigations to look for an underlying cause (Hyperhidrosis: CKS 2009).