Hyperhidrosis is often underrecognized and undertreated. Published survey data suggest gaps in primary care familiarity with available therapies, while patients frequently report long delays before seeking care and substantial effects on work, clothing choices, social activities, and daily life.^1,2

Before treatment begins, new-onset, generalized, asymmetric, or nighttime sweating should be evaluated for secondary causes, including medications, endocrine disorders, infection, neurologic disease, malignancy, menopause, and other underlying medical conditions.³

We offer comprehensive medical management of hyperhidrosis using evidence-based topical, systemic, and adjunctive treatments, with referral for procedural options when appropriate.⁴

Traditional Systemic Treatments

Beta Blockers, Particularly Propranolol

Propranolol is a cardiovascular medication used off-label for predictable, stress-related or performance-related sweating. It can reduce the physical stress response that accompanies anxiety and may be helpful before presentations, interviews, performances, social events, or other situations in which anxiety reliably triggers sweating. It is generally more useful for situational sweating than for primary hyperhidrosis that occurs independently of stress. Published hyperhidrosis guidance discusses propranolol most often; evidence supporting atenolol specifically is limited.^4,5

Propranolol is not appropriate for everyone. Patients should be screened for conditions such as asthma or bronchospasm, low blood pressure, a slow heart rate, and certain cardiac conduction disorders. It may also mask symptoms of low blood sugar in susceptible patients.⁵

Oral Glycopyrrolate

Glycopyrrolate is an oral antimuscarinic medication used off-label for hyperhidrosis. It reduces acetylcholine-mediated stimulation of eccrine sweat glands throughout the body. It may be useful for generalized or multifocal hyperhidrosis and for areas that are difficult to treat with topical medication, including craniofacial sweating. Dosing is individualized and usually adjusted gradually according to symptom response and adverse effects.^4,5,6,7

Evidence for oral glycopyrrolate in hyperhidrosis comes primarily from observational studies, small patient cohorts, systematic review of limited studies, and clinical experience rather than large, definitive randomized trials.^6,7

Potential disadvantages include dry mouth, blurred vision, constipation, urinary retention, drowsiness, confusion, and reduced ability to sweat normally. Because anticholinergic medications can impair heat dissipation, patients should be cautious during strenuous exercise or exposure to high temperatures. Older adults are more vulnerable to urinary retention, bowel obstruction, delirium, falls, and other anticholinergic complications. These effects may prevent some patients from tolerating an effective dose.^7,8

Advanced Topical Treatment

Sofpironium Topical Gel (Sofdra)

Sofdra (sofpironium) topical gel, 12.45% is an FDA-approved anticholinergic treatment for primary axillary hyperhidrosis in adults and children 9 years of age and older. It is applied once daily at bedtime using one pump per underarm. Sofpironium inhibits acetylcholine receptors involved in sweat-gland stimulation.⁹

Sofpironium was designed as a rapidly metabolized topical anticholinergic. Its topical administration directs treatment to the underarm area, but measurable systemic absorption occurs, and systemic anticholinergic adverse effects remain possible. Sofdra should therefore not be described as purely localized or free of systemic risk.^9,10

In the pivotal CARDIGAN trials, treatment produced statistically significant improvements in patient-reported underarm sweating severity and frequency. In CARDIGAN 1, 49% of Sofdra-treated participants achieved at least a 2-point improvement in the HDSM-Ax-7 score by day 43, compared with 29% using vehicle. In CARDIGAN 2, the corresponding response rates were 64% and 48%.^9,10

Systemic adverse effects were not eliminated. Across the pivotal trials, dry mouth occurred in 14% of Sofdra-treated participants, blurred vision in 9%, pupil dilation in 7%, and urinary retention in 2%. Local reactions included application-site pain, redness, dermatitis, itching, irritation, and exfoliation. Sofdra also carries warnings concerning urinary retention, heat illness caused by decreased sweating, and transient blurred vision.⁹

Sofdra should be applied only to clean, dry, intact underarm skin. Patients should use the supplied applicator, wash their hands immediately after application, avoid transferring the medication to the eyes, and keep it away from heat, flames, and smoking because the gel is flammable.⁹

Our Treatment Approach

• Stress-related or anxiety-linked sweating: Consider event-based propranolol when clinically appropriate, following screening for cardiovascular and pulmonary contraindications.^4,5
• Primary axillary hyperhidrosis: Optimize aluminum chloride antiperspirant therapy when appropriate and consider Sofdra as a targeted prescription option when antiperspirants are inadequate, poorly tolerated, or not preferred. Treatment selection also depends on age, medical history, contraindications, cost, and patient preference.^4,9,11
• Generalized, multifocal, or craniofacial sweating: Evaluate for secondary causes first. Oral glycopyrrolate may be considered when its expected benefit outweighs systemic anticholinergic risks.^3,4,6,7,8
• Palmar, plantar, or treatment-resistant focal sweating: Consider iontophoresis, botulinum toxin injections, combination treatment, or referral for site-specific procedural interventions.^4,11
• Adjunctive measures: Optimize the timing and application of clinical-strength antiperspirants, identify avoidable triggers, and use breathable or moisture-managing fabrics and practical clothing strategies alongside prescription treatment.^4,11

Hyperhidrosis can affect confidence, emotional well-being, social participation, education, relationships, and career opportunities. It is a treatable medical condition, and patients do not have to accept excessive sweating as something they must simply live with.^2,12

The best treatment plan depends on the distribution and severity of sweating, possible secondary causes, age, medical history, medication list, occupational heat exposure, treatment goals, and tolerance for adverse effects.^3,4

Clinical note: Propranolol and oral glycopyrrolate are used off-label for hyperhidrosis. All prescription treatments require an individualized clinical evaluation and monitoring plan.^5,8

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References

1. Lee ACH, Ferguson MK. Knowledge of surgical management of hyperhidrosis among primary care physicians and the general public. Interact Cardiovasc Thorac Surg. 2022;34(5):791-798. doi:10.1093/icvts/ivab371
2. Glaser DA, Hebert A, Pieretti L, Pariser D. Understanding patient experience with hyperhidrosis: a national survey of 1,985 patients. J Drugs Dermatol. 2018;17(4):392-396. PubMed
3. Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: a comprehensive review. Part I. Etiology and clinical work-up. J Am Acad Dermatol. 2019;81(3):657-666. doi:10.1016/j.jaad.2018.12.071
4. Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: a comprehensive review. Part II. Therapeutic options. J Am Acad Dermatol. 2019;81(3):669-680. doi:10.1016/j.jaad.2018.11.066
5. Glaser DA, Glaser K. Use of systemic therapies to manage focal hyperhidrosis. Mo Med. 2015;112(4):287-291. Full text
6. Lee HH, Kim DW, Kim DW, Kim C. Efficacy of glycopyrrolate in primary hyperhidrosis patients. Korean J Pain. 2012;25(1):28-32. doi:10.3344/kjp.2012.25.1.28
7. Cruddas L, Baker DM. Treatment of primary hyperhidrosis with oral anticholinergic medications: a systematic review. J Eur Acad Dermatol Venereol. 2017;31(6):952-963. doi:10.1111/jdv.14081
8. DailyMed. Glycopyrrolate tablets prescribing information. Revised May 2023. Updated May 18, 2025. Accessed June 21, 2026. Prescribing information
9. US Food and Drug Administration. Sofdra (sofpironium) topical gel, 12.45% prescribing information. Revised June 2024. Accessed June 21, 2026. FDA prescribing information
10. Pariser D, Glaser DA, Del Rosso J, et al. Sofpironium topical gel, 12.45%, for the treatment of axillary hyperhidrosis: pooled efficacy and safety results from 2 phase 3 randomized, controlled, double-blind studies. J Am Acad Dermatol. 2025;93(1):82-88. doi:10.1016/j.jaad.2025.02.086
11. American Academy of Dermatology Association. Hyperhidrosis: diagnosis and treatment. Accessed June 21, 2026. AAD treatment guidance
12. Parashar K, Adlam T, Potts G. The impact of hyperhidrosis on quality of life: a review of the literature. Am J Clin Dermatol. 2023;24(2):187-198. doi:10.1007/s40257-022-00743-7