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Author: Dr Tom Moodie, Dermatology Registrar, Waikato Hospital, Hamilton, New Zealand, 2013.
Anticholinergic medications are a class of drug that block the neurotransmitter acetylcholine in the central and peripheral nervous system. They are used to treat a wide variety of conditions associated with activation of the parasympathetic nervous system.
In dermatology, anticholinergics are used to help control hyperhidrosis.
The most commonly prescribed anticholinergics for hyperhidrosis are:
Anticholinergic drugs competitively inhibit binding of the neurotransmitter, acetylcholine. They target either muscarinic acetylcholine receptors or, less commonly, nicotinic acetylcholine receptors.
Side effects of anticholinergics include:
Side effects from anticholinergics are relatively common, especially in the elderly, and frequently lead to discontinuation of their use.
Anticholinergics should be used with caution in people with:
Anticholinergic medications have potential interactions with many other drugs, especially those with cholinergic actions or anticholinergic side effects. They are best avoided when taking another anticholinergic medication.
Anticholinergic effect is enhanced by:
Acetylcholinesterase inhibitors used in myasthenia gravis and Alzheimer disease can antagonise the action of anticholinergic medications.
Most anticholinergics are pregnancy category B2. This means that safety in pregnancy has not been well established. They should not be used in pregnant women or those likely to become pregnant unless the expected benefits outweigh any potential risk.
Oxybutinin is the best studied agent used for excessive sweating. It has proven to be effective for palmar and axillary hyperhidrosis in 50% of patients treated with 5 mg twice daily. It is also effective for facial hyperhidrosis.
Glycopyrrolate is an ionised drug that targets the M3 receptors, a subset of muscarinic receptors found in glandular tissue. It has a lower incidence of neurological and ocular side effects compared with other anticholinergics. Glycopyrrolate is available as topical and oral formulations.
Propantheline can be used topically and orally to treat hyperhidrosis. The dose is 15–30 mg four times per day. Introduced in the 1970s, there are no contemporary studies evaluating propantheline for hyperhidrosis.
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