Aside from the topical and herbal treatments discussed on the Home Remedy page, medications can be taken internally, usually by mouth, that may help dry up excessive sweating. Some patients may suffer from sweating as a symptom of an anxiety disorder, such as agoraphobia, panic disorder, or social anxiety disorder, where they get unreasonably nervous in certain situations. People with these problems are often best treated with specific psychiatric medications to control their anxiety, or with psychotherapy. However, they may still require symptomatic treatments to help control their bodily reactions to these situations; the decision to use medications for these conditions is best left up to their treating physician or psychiatrist.

For the condition known as stage fright, where otherwise calm people may get so nervous if they have to speak or perform in public, some physicians recommend using a small dose of a drug known as a beta blocker, such as propranolol (Inderal®), prior to the public appearance. This medication may help calm the jitters, and may prevent the tremor, cracking voice, rapid heartbeat, and even the sweating that public appearances may produce in some people, as it chemically blocks the sympathetic nerve endings, but at a different point than the acetylcholine blocking drugs do. Beta-blockers are often used for high blood pressure, angina, heart disease, and migraines, but must be used very carefully, especially by people with asthma, diabetes or lung diseases, and are only available by prescription. Physicians have often found the combination of Robinul® and propranolol to be very effective.

For many people who suffer from diffuse sweating, hyperhidrosis or facial blushing, anticholinergic medications may be the best treatment. These medications work by preventing the neurotransmitter acetylcholine from signaling the sweat glands at the end of the sympathetic nerves. However, they also block many of the signals of the parasympathetic nerves, which accounts for their other pharmaceutical effects, which may include dry mouth (they are used for drooling and to prevent saliva production in dentistry), blurred vision with dilated pupils (many are used in ophthalmology in eye drop form), urinary problems (some are used to treat frequent urination or irritable bladder), constipation (some anticholinergics are used to treat irritable bowel syndrome or intestinal spasms), drying of secretions (which is why some are indicated to help with stomach ulcers or for use in anesthesia), rapid heartbeat/palpitations, and side effects related to their effect on the brain. Since anticholinergic medications affect many nerves, they may have many different effects on different parts of the body; some of them work better for some conditions than others. Glycopyrrolate, (brand name Robinul®) for example, has little or no effect on the brain, as it does not get into the blood supply to the brain.

For hyperhidrosis, the most commonly used drugs are the anticholinergics and the antidepressants glycopyrrolate (Robinul® and Robinul® Forte), atropine, propantheline bromide (ProBanthine®) and oxybutynin (Ditropan®). All require prescription in the United States. None of these drugs are formally indicated for use in hyperhidrosis, but many physicians have found them to be extremely helpful (Abell E & Morgan K, The treatment of idiopathic hyperhidrosis by glycopyrronium bromide and tap water iontophoresis, Br. J. Dermatol 1974, 91:87-91). By blocking the acetylcholine neurotransmitter, they cut down on the nerve impulses to the sweat glands, thus lowering the amount of perspiration produced. Since they are usually taken orally, they go throughout the entire body, which can be an important feature for people who have hyperhidrosis at many different sites where topical treatments (such as antiperspirants or iontophoresis), or even surgery cannot control sweating everywhere. In addition, these medications produce temporary, reversible effects, so that a person can choose when to use them. If a sufferer knows that a certain situation is going to make them sweat, they may choose to take the medication in advance to be prepared. They can also be used on a regular basis to control the sweating routinely, or can be adjusted to just "take the edge off" the excessive sweating. Side effects may vary, depending on the medication, the dose and the individual patient, and should be monitored closely by the patient and the prescribing physician. Most of these medications will cause a dry mouth, which is why some are also used to help control drooling.

Glycopyrrolate (Robinul® and Robinul® Forte) tablets come in two different strengths (Robinul® 1mg and Robinul® Forte 2 mg), so the dose can be easily adjusted. The tablets can also be crushed up and given mixed with soft foods such as applesauce, pudding, ice cream, etc., or made into a liquid form by a pharmacist, if swallowing tablets are a problem. Glycopyrrolate is usually taken 1 to 3 times a day, in doses of 1 or 2 mg at a time, depending on the severity of the sweating. Side effects are few and usually very mild and not that bothersome. Some patients may develop a dry mouth. Patients who tend to get diarrhea frequently may find that the glycopyrrolate tends to help control that, as it is used for diarrhea in other countries. Glycopyrrolate does not cross the blood-brain barrier, therefore Central Nervous System (CNS) side-effects are virtually non-existent.

Atropine tends to have more side effects than the others do; because it gets into the brain very easily, it is more likely to produce drowsiness, restlessness, irritability, or even mental confusion. It is the shortest acting of the four anticholinergics, and needs to be taken every 4-6 hours. Oxybutynin is often used to help calm down bladder spasms and an overactive bladder, while propantheline bromide is used for stomach ulcers as well as for bladder spasms. However, they need to be taken 2-5 times a day, and the propantheline tablets cannot be split.

Usually, the best way to adjust these medications is by trial and error. Multiple medications and schedules may be tried before finding a treatment that works best for that individual patient. The anticholinergics are much less likely to cause rashes and skin irritation than the antiperspirants, and the dose can be adjusted fairly easily. Some people may need only a fraction of one tablet a day to control their hyperhidrosis, while others may need higher doses. Some physicians have used these anticholinergics by iontophoresing them into the skin, in a manner similar to the tap-water electrophoresis described before, but scientific studies have shown that they also work well when formed into topical skin preparations. Topical gels, lotions and creams containing anticholinergics such as Robinul® (glycopyrrolate) can be compounded up fairly easily by many pharmacists, and so they may be applied onto the skin at particularly bothersome sites, as was reported in the papers on gustatory sweating in diabetes (Atkin Sl & Brown PM, Treatment of diabetic gustatory sweating with topical glycopyrrolate cream, Diabetic Medicine 1996, 13:493-494) or Frey's syndrome (Hays LL, et al, The Frey syndrome: a simple, effective treatment, Otolaryngol. Head Neck Surg. 1982, 90:419-425). Of course, for people who suffer from hyperhidrosis throughout their entire body, topical cream treatment is probably not as desirable as oral tablet therapy. The ability to control excessive sweating by taking a simple tablet may make the other treatments seem less desirable.

Finally, a relatively new medication that is being tried is the local injection of botulism, a toxin (Botox®), which semi-permanently blocks the acetylcholine neurotransmitter where it is injected. This treatment may be painful, and expensive, and will only work for the small areas of skin around the injection site; however, for people who are bothered by hyperhidrosis at only a few sites (such as the hands or armpits, Odderson I R, Axillary hyperhidrosis: treatment with botulinum toxin A, Arch. Phys. Med. Rehabil. 1998, 79:350-352), this may be an option. Many insurance companies will not cover the cost, which can range from $5,000 - $10,000.

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