Psychopharmacology Reviews: Topiramate Treatment of Social Anxiety Due To Uncontrollable Facial Sweating

David L. Ginsberg, MD

Director of Outpatient Services, Tisch Hospital’s Department of Psychiatry, New York University Medical Center

Introduction

Physiologic symptoms, such as excessive sweating or hyperhidrosis, are common in SAD and may be the primary reason for seeking treatment. Compared to symptoms of fear and avoidance in SAD, physiologic symptoms tend not to respond as well to standard treatments with SSRIs or CBT. In fact, sweating may occur as a side effect of SSRIs. Now comes a study indicating that the anticonvulsant topiramate may also be effective for treating uncontrollable sweating.

The Case

A 41 year-old, successful, male executive was in good health, except for his history of panic disorder since childhood. Attacks occurred from once a night to up to 5 times daily, both spontaneously and in social situations, and lasted up to 2 hours. The attacks were followed by exhaustion. Excessive sweating was familial, with the patient’s mother having a history of sweating profusely, particularly when anxious.

The patient entered therapy at age 32 and received clonazepam and paroxetine for 7 years. Well tolerated, these psychotropic medications controlled some of the panic symptoms, but not the conditioned responses of hyperhidrosis that occurred in professionally demanding situations such as negotiations, confrontations with employees, or public speaking. CBT and a brief trial of mirtazapine did not reduce the hyperhidrosis. At this point, the patient was considering undergoing thoracic sympathectomy.

The Treatment

In an effort to prevent such a radical intervention, a trial of topiramate, added to his current regimen of paroxetine and clonazepam, was initiated. Topiramate was started at 50 mg/day and after 2 weeks was increased to 100 mg twice daily. After 2 weeks on a dose of 100 mg twice a day, the patient noticed some decrease in sweating. Topiramate was then increased to 200 mg twice a day, with sweating subsequently reduced to a tolerable level throughout the whole day. The patient was able to conduct demanding social interactions without embarrassment. At last follow-up, he remained free of panic attacks and reported that he experienced only mild episodes of hyperhidrosis once or twice a month. Overall, despite the side effects of tiredness and mild cognitive slowing, he described feeling satisfied with the outcome of the topiramate trial.

Conclusion

The incidence of hyperhidrosis in younger individuals is 0.6%–1.0%, with 25% familial involvement. It may occur as generalized or localized, with the latter type typically beginning in childhood or adolescence. Facial hyperhidrosis, however, usually requires sympathectomy with surgical destruction of the first and second sympathetic thoracic ganglia. Unfortunately, the success rate for facial hyperhidrosis is lower than that for other types of hyperhidrosis. Topiramate is known to reduce sweating, probably at the level of the sweat glands, and has been successful in the treatment of palmar-plantar hyperhidrosis. The mechanism of action underlying this effect is not fully understood but may involve inhibition of carbonic anhydrase isoenzymes localized in sweat glands. Regardless of the mechanism of action, topiramate may be a useful option for those with significant facial sweating. Controlled clinical trials are indicated to confirm this preliminary report.

Disclosure: Dr. Ginsberg reports no affiliations or financial interests in any organization that may pose a conflict of interest.